Hasta ve Çalışan Güvenliği Kapsamında Gerçekleşen İstenmeyen Olay Bildirimlerinin Analizi: Bir Kamu Hastanesi Örneği

Yıl 2024, , 316 - 328, 15.10.2024

Burçin Nur Özdemir , İrem Malatyalı

https://doi.org/10.26466/opusjsr.1508886

Öz

Bu çalışmada, bir kamu hastanesinde bildirimi yapılan istenmeyen olayların hasta ve çalışan güvenliği kapsamında analiz edilerek hatalardan öğrenmeye yönelik çalışmaların geliştirilmesi ve sağlık çalışanlarının farkındalıklarının artırılarak sağlık hizmet sunum kalitesinin artırılması amaçlanmıştır. Araştırma nicel araştırma tasarımı olan tanımlayıcı, kesitsel ve retrospektif olarak tasarlanmıştır. Veriler araştırmacı tarafından oluşturulan veri toplama formu ile Hastane Bilgi Yönetim Sistemi ve yazılı kayıtlardan elde edilmiştir. Veriler 01.01.2022-30.12.2023 tarihleri arasında bilidirimi yapılan istenmeyen olaylardan elde edilmiştir. Araştırmadan elde edilen bulgulara göre; 2022 yılında toplam 3447 hasta güvenliği istenmeyen olay bildirimi gerçekleşmiş olup bunların 19’unun düşme, 8’inin ilaç güvenliği, 5’nin transfüzyon güvenliği, 3415’inin laboratuvar güvenliği olduğu tespit edilmiştir. 2023 yılında toplam 4788 hasta güvenliği istenmeyen olay bildirimi gerçekleşmiş olup bunların 37’sinin düşme, 20’sinin ilaç güvenliği, 2’sinin transfüzyon güvenliği, 4729’sinin laboratuvar güvenliği olduğu tespit edilmiştir. 2022 yılında toplam 111 çalışan güvenliği istenmeyen olay bildirimi gerçekleşmiş olup bunların 59’unun kesici-delici alet yaralanması, 9’unun kan ve vücut sıvısı sıçraması, 45’inin hukuka yansımış olay olduğu tespit edilmiştir. 2023 yılında toplam 120 çalışan güvenliği istenmeyen olay bildirimi gerçekleşmiş olup bunların 63’ünün kesici-delici alet yaralanması, 6’sının kan ve vücut sıvısı sıçraması, 51’inin hukuka yansımış olay olduğu tespit edilmiştir. İstenmeyen olay bildirimlerinin 2022-2023 yılları karşılaştırıldığında bildirim sayısının yıllara göre artış gösterdiği ve bununda kurumda bir raporlama kültürünün oluştuğunu göstermektedir. Araştırma sonucunda; bilidirimi en fazla yapılan istenmeyen olayların laboratuvar güvenliği ve kesici-delici alet yaralanmalarının olduğu tespit edilmiştir.

Anahtar Kelimeler

Hasta güvenliği, çalışan güvenliği, istenmeyen olay bildirimi, raporlama kültürü

Analysis of Adverse Event Notifications Within the Scope of Patient and Employee Safety: An Example of a Public Hospital

Öz

This study aimed to analyze the adverse events reported in a public hospital within the scope of patient and employee safety, to develop studies aimed at learning from errors and to increase the awareness of healthcare professionals and to increase the quality of healthcare service provision. The research was designed as a descriptive, cross-sectional, and retrospective quantitative research design. Data were obtained from the Hospital Information Management System and written records with the data collection form created by the researcher. Data were obtained from the adverse events reported between 01.01.2022 and 30.12.2023. According to the findings of the research; A total of 3447 patient safety adverse event reports were made in 2022, and it was determined that 19 of them were falls, 8 were medication safety, 5 were transfusion safety, and 3415 were laboratory safety. A total of 4788 patient safety adverse event reports were made in 2023, and it was determined that 37 of them were falls, 20 were medication safety, 2 were transfusion safety, and 4729 were laboratory safety. In 2022, a total of 111 employee safety undesirable incidents were reported, of which 59 were sharp-edged injuries, 9 were blood and body fluid splashes, and 45 were legal incidents. In 2023, a total of 120 employee safety undesirable incidents were reported, of which 63 were sharp-edged injuries, 6 were blood and body fluid splashes, and 51 were legal incidents. When the 2022-2023 undesirable incident reports are compared, it is seen that the number of reports has increased over the years, which indicates that a reporting culture has been formed in the institution. As a result of the research; It was determined that the most reported undesirable incidents were laboratory safety and sharp-edged injuries.

Anahtar Kelimeler

Patient safety, employee safety, adverse event reporting

Etik Beyan

İstanbul Üniversitesi Cerrahpaşa sosyal ve beşeri bilimler etik kurulundan etik kurul izni alınmıştır.

Destekleyen Kurum

Herhangi bir kurumdan destek alınmamıştır.

Kaynakça

• Akar, Y., Erduran, S., Uğurlu, D., & Özyurt, E. (2019). Evaluation of safety reporting system notifications by years (2016-2017-2018). Health Academicians Journal, 6(2), 81-86.
• Akgün, S. (2014). Patient safety, unexpected serious medical errors -sentinel events-sentinel events in healthcare. Health Academicians Journal, 1, 75-82.
• Alrwisan, A., Ross, J., & Williams, D. (2011). Medication incidents reported to an online incident reporting system. European Journal of Clinical Pharmacology, 67, 527-532.
• Aslan, Y. (2020). Evaluation of medication-related medical error/incident notifications according to the World Health Organization "Patient Safety International Classification". Journal of Health Science and Medicine, 3(1), 20-25. https://doi.org/10.32322/jhsm.612510
• Aygin, D., Yaman, Ö., & Bitirim, E. (2020). Medication administration errors: Emergency department example. Balıkesir Health Sciences Journal, 9(2), 75-82.
• Bozoğlan, H. (2015). Emergency department worker safety (Master's thesis). Istanbul.
• Catalano, K., & Fickenscher, K. (2008). Complying with the 2008 National Patient Safety Goals. AORN Journal, 87, 547–556.
• Canadian Patient Safety Institute (CPSI). (2011). Canadian disclosure guidelines: Being open to patients and families. Ottawa.
• Elhence, P., Shenoy, V., Verma, A., & Sachan, D. (2012). Error reporting in transfusion medicine at a tertiary care centre: A patient safety initiative. Clinical Chemistry and Laboratory Medicine, 50(11), 1935-1943.
• Ernawati, D. K., Lee, Y. P., & Hughes, J. D. (2014). Nature and frequency of medication errors in a geriatric ward: An Indonesian experience. Therapeutics and Clinical Risk Management, 10, 413-421.
• Fastman, B. R., & Kaplan, H. S. (2011). Errors in transfusion medicine: Have we learned our lesson? Mount Sinai Journal of Medicine, 78, 854-864.
• Grober, E. D., & Bohnen, J. M. (2005). Defining medical error. Canadian Journal of Surgery, 48(1), 39-44.
• Gudik-Sørensen, M. (2013). Patient safety: Analyzing medication-related adverse events. European Journal of Hospital Pharmacy, 20, A1-238.
• Institute of Medicine (IOM). (2003). To err is human: Building a safer health system. Washington, DC: National Academies Press.
• JCAHO. (2002). Approves National Patient Safety Goals for 2003. Joint Commission Perspectives, 22, 1-3.
• Karagözoğlu, Ş., Otu, M., & Coşkun, G. (2019). Nurses' thoughts and habits of reporting medication errors in a research and practice hospital. Cumhuriyet University Health Sciences Institute Journal, 4(1), 26-39.
• Leape, L. L. (1994). Error in medicine. JAMA, 272, 1851-1857.
• Liang, B. (2002). A system of medical error disclosure. Quality and Safety in Health Care, 11, 64-68.
• Maskens, C., Downie, H., Wendt, A., Lima, A., Merkley, L., Lin, Y., & Callum, J. (2013). Hospital-based transfusion error tracking from 2005 to 2010: Identifying the key errors threatening patient transfusion safety. Transfusion, 54(1), 66-73.
• Meydanlıoğlu, A. (2013). Health and safety of health care workers. Health Sciences Journal, 2(3), 192-199.
• Pıçakçıefe, I. M., Kıcalı, R. Ü., Vatandaş, M. O., & Ata, Ş. (2024). Effects of sociodemographic characteristics, working conditions, and excessive daytime sleepiness on sharps injuries in healthcare workers. Nobel Medicus Journal, 20(1), 14-21.
• Public Health Agency of Canada (PHAC). (2015). Transfusion error surveillance system (TESS) - 2012-2013 report. Centre for Communicable Diseases and Infection Control.
• Reason, J. (1990). Human error. Cambridge: Cambridge University Press.
• Sezgin, B. (2007). Evaluation of working environment and nursing practices in hospitals with quality certificates in terms of patient and nurse safety (Doctoral dissertation). Istanbul University Institute of Health Sciences, Istanbul.
• Ministry of Health. (2020). Healthcare Quality Standards Version 6.0 Hospital Set. Healthcare Quality, Accreditation and Employee Rights Department.
• Ministry of Health. (2022). National Patient Safety Goals. https://shgmkalitedb.saglik.gov.tr/TR-95193/ulusal-hasta-guvenligi-hedefleri.html (Accessed on 13.08.2024).
• Ministry of Health. (2017). Safety Reporting System (GRS) 2017 Statistics and Analysis Report. Healthcare Quality and Accreditation Department, Ankara.
• Ministry of Health. (2011). Regulation on Ensuring Patient and Employee Safety. https://shgmkalitedb.saglik.gov.tr/TR-6612/hasta-ve-calisan-guvenliginin-saglanmasina-dair-yonetmelik-2011.html (Accessed on 13.08.2024).
• The Joint Commission International (JCI). (2017). Hospital accreditation standards (6th ed.). Joint Commission Resources, USA.
• Tak, B. (2010). Establishing patient safety systems as the main element of quality in health services: A roadmap proposal for hospitals. Journal of Performance and Quality in Healthcare, 1, 72-113.
• Victorian Government Department of Human Services. (2008). Serious transfusion incident report: Blood matters – Better safer transfusion program 2006-07. Statewide Quality Branch, Rural and Regional Health and Aged Care Services, Victorian Government Department of Human Services, Melbourne, Victoria.
• Vincent, C. (2010). Patient safety. Wiley‐Blackwell.
• Vijenthira, S., Armali, C., Downie, H., et al. (2021). Registration errors among patients receiving blood transfusions: A national analysis from 2008 to 2017. Vox Sanguinis, 116(2), 225-233.
• Yao, C. Y., Chien, J. H., Chuang, H. Y., & Ho, T. F. (2020). Associated factors with acute transfusion reaction from hospital online reporting events: A retrospective cohort study. Journal of Patient Safety, 16(4), e303–e309. https://doi.org/10.1097/PTS.0000000000000527
• Wundavalli, L., Bulkapuram, S. G., Bhaskar, N. L., & Satyanarayana, N. (2018). Patient safety at a public hospital in southern India: A hospital administration perspective using a mixed methods approach. The National Medical Journal of India, 31(1), 39-43.
• World Health Organization (WHO). (2005). Draft guidelines for adverse event reporting and learning systems.
• World Health Organization (WHO). (2009). Conceptual framework for the international classification for patient safety: Final technical report.
• World Health Organization (WHO). (2010). Guidelines for critical incident reporting: Critical incident reporting in hospitals.