Ensuring patient safety in an emergency primary health care service

Orellana Carrasco R, Zájara Porras M, Shevnina N, Rojas Quero M, Báez Cabeza A, Pérez-Montaut Merino I

Objective: Clinical safety and the risks affecting patients in their relations with the health

care system have long been discussed in the health sciences. Certain settings, such as

critical care units, are highly susceptible to error because of the many drugs and

procedures they manage. Our main objetive was to initiate analysis of adverse events in

an emergency primary health care service, as well as to facilitate the identification and

prevention of such events.

Methods: A working group was formed in November 2007 in our emergency primary

health care service and charged with defining situations in which there is risk of adverse

events, preventing such events, and analyzing and correcting those that occurred with a

view to making ongoing improvements in patient care. We undertook a retrospective

study of adverse event reports in 2008.

Results: We attended 75 525 consultations, and found 11 incidents (0,15‰). Nine

were caused by errors in identifying the onset of the episode (referral errors) and 2 were

events with scarce clinical consequences.

Conclusions: Mistakes in identifying the onset of a clinical episode or relevant medical

history are the most common type of event. This error generates the need for an

emergency department visit that could have been avoided if the error had been

corrected in time.

Báez Cabeza A, Orellana Carrasco R, Pérez-Montaut Merino I, Rojas Quero M, Shevnina N, Zájara Porras M