Sentinel event in obstetric care: preventing falls
Keywords:
Sentinel Surveillance, Patient Safety, Patient care, Obstetrics, Accidental Falls, Accident PreventionAbstract
Introduction: The patient safety is one aspect that has gained importance for health systems globally. Health care and nursing in the hospital and ambulatory settings, as well as the provision of some other health services are being rendered unsafe and adding unnecessary risks to patients.
Objetive: Monitor and systematize the indicator “fallen in obstetric patient” (sentinel event) to assess the quality of care in
nursing.
Description: Against this background, the nursing staff assigned to Unidad Médica de Alta Especialidad, Hospital de Ginecología y Obstetricia No. 23 del Instituto Mexicano del Seguro Social, concerned about the safety of patients, design and apply a safety index to reduce or avoid falls (sentinel event). The instrument "checklist" was validated by experts; later in the clinical and departmental meetings will be introduced and trained staff in the filling and collection of information. The information was analyzed by applying descriptive statistics. The checklist consists of seven questions that the nurse responsible must answer before mobilizing the patient out of bed for the first time. This instrument was
included as part of the blade of medical indications.
Conclusions: Since implementing this strategy, the number of falls in patients has decreased significantly. Therefore the measurement and monitoring of this strategy has been determined to improve the quality of nursing care. Besides the
checklist has been used as an instrument evidence that procedure was performed.
References
Organización Panamericana de la Salud. Noticias e Información Pública. Líderes de salud lanzarán alianza global por seguridad del paciente [en línea] http://www.paho.org/Spanish/DD/PIN/ps041026.htm [Consultado 15/11/07]
Navarro C, Domínguez M, Cuesta F, Roitz H, Lazaro M, Ribera JM. Caídas en el anciano. JANO.1998;55(1263):36-9.
Institute of Medicine. Crossing the Quality Chasm: A new health system for the 21st century. Washington D.C. Institute of Medicine, 2001.
Tapia VM, del Carmen Salazar CM, Tapia CL, Olivares RC. Prevención de caídas. Indicador de calidad del cuidado enfermero. Rev Mex Enf Cardiol.2003;11(2):51-57.
Reason J. Human error: models and management. BMJ.2000;320(7237):768-70.
Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington D.C, Committee on Quality of Health Care in America, Institute of Medicine, 1999.
Agra Y, Terol E. La seguridad del paciente: una estrategia del Sistema Nacional de Salud. An sis San Navarra. 2006;29(3):319-323.
Secretaría de Salud. México. Seguridad del paciente en la atención médica. [en líneas] http://www.innovaciony calidad.salud.gob.mx/10pasos.php [Consultado 30/04/07]
Bueno-Cavanillas A, Padilla-Ruiz F, Peinado-Alonso C, Espigares-García M, Gálvez-Vargas R. Factores de riesgo de caídas en una población anciana institucionalizada. Estudio de cohortes prospective. Med Clin.1999;112(1):10-5.
