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[Implementation of a Plan of Patient Safety in Service of Pediatric Surgery. First results].

OBJECTIVES
In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained.


METHODS
For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed. The evaluation team was composed by experienced pediatric surgeon, two staff nurses, and a doctor and nurse from the Quality Department.


RESULTS
95 clinical records and a total of 406 days of hospital stay were reviewed. 31 patients (32.6%) experienced one or more AE. Total AE: 43. The AE/1000 patients/day ratio: 105.9. The most common AE were: vomiting, itching and pain. 28 EA were considerd mild and 3 moderate in severity, according to the classification of the National Coordinating Council for Medication Error Reporting and Prevention. No EA were considered serious or critical.


CONCLUSIONS
The analysis of prevalence through regular assessments of medical records is an easy method to obtain information about the frequency of occurrence, exact understanding of the AE types and the implementation of corrective measures. The main limitation of this method is that it can miss some of the serious EA and miss the records and analysis of sentinel events that may occur in the period between assessments.