BACKGROUND AND OBJECTIVE

Proper documentation of patient safety events is important to be able to provide changes that can prevent events from occurring again. The Philippine General Hospital launched an online platform for reporting patient safety events in 2017. This paper aimed to describe the patient safety events, initial response to the event, and preventive actions done in the institution.

METHODS

This is a retrospective descriptive study of patient safety event records from August 2017 to April 2022. General data of the patients, details surrounding the events, response to the event, and preventive measures done after the event were documented. Descriptive analysis was performed.

RESULTS

There was a total of 625 events reported with 525 total unique reports. There was an increased rate of patient safety event reports from 2021 to 2022. The average rate was 23.8 and 25.7 reports per month, respectively. Most reports were for in-patient cases and were type 3 preventable adverse events. The general initial response of healthcare personnel to the adverse events is to provide the appropriate clinical care. Preventive measures include re-orientation and event specific actions.

CONCLUSION

Documentation is crucial for patient safety events to provide solutions and prevent reoccurrence of these events that can cause harm to patients.

Human ; Healthcare Quality ; Quality Of Health Care ; Medical Errors ; Patient Safety ; Patient Harm

patient harm.TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0004172]]>
Arm ; Information Services ; Infusion Pumps ; Medication Errors ; Methods ; Patient Harm ; Prospective Studies ; Syringes

Colonoscopy is currently regarded as the gold standard and preferred method of screening for colorectal cancer (CRC). However, the benefit of colonoscopy screening may be blunted by low participation rate in population-based screening program. Harmful effects of population-based colonoscopy screening may include complications induced by colonoscopy itself and by sedation, psychosocial distress, potential over-diagnosis and socioeconomic burden. In addition, harmful effect of colonoscopy may increase with age and comorbidity. As the adverse event risk in population-based colonoscopy screening may offset benefit of the screening colonoscopy, the adverse events associated with screening colonoscopy should be well managed and monitored. To adopt population-based colonoscopy screening, consensus for the risk and benefits of screening colonoscopy should be formed for its potential harms, patient preference, socioeconomic considerations, quality improvement of colonoscopy as well as its efficacy for CRC prevention. As the suboptimal colonoscopy quality is a major pitfall of population-based colonoscopy screening, adequate training and provider regulation for screening colonoscopists should be the first step to minimize the variation of quality between colonoscopists. Gastroenterologists should lead quality improvement, auditing, and training associated with colonoscopy in a population-based colonoscopy screening program.
Colonic Neoplasms ; Colonoscopy ; Colorectal Neoplasms ; Comorbidity ; Consensus ; Mass Screening ; Methods ; Patient Harm ; Quality Improvement

Central venous catheterization is common in the emergency department for monitoring of CVP (central venous pressure), fluid administration, and drug infusions. However, the insertion of a central venous catheter is a technically challenging procedure with known risks and complications. A 94-year-old woman was transferred to an emergency department due to difficulties in removing the guidewire during central catheter insertion through the right subclavian vein. A focused bedside ultrasound showed that the guidewire was improperly positioned in the right internal jugular vein. Upon computed tomographic evaluation, the guidewire perforated the right subclavian vein, looped in the mediastinum, reentered the right internal jugular vein toward the right jugular foramen, and was removed by surgery. In conclusion, as catheter and guidewire entrapment are well-known potential complications of central venous catheterization, when resistance is encountered at any stage of central venous catheterization (especially when removing the entrapped catheter or guidewire) the procedure should be stopped and evaluated with imaging assistance. Clinicians should be aware of more complicated sequelae caused by blunt removal of an entrapped catheter and guidewire, despite its low probability.
Catheterization ; Catheterization, Central Venous* ; Catheters ; Central Venous Catheters* ; Emergencies ; Female ; Humans ; Jugular Veins ; Mediastinum ; Patient Harm ; Subclavian Vein ; Ultrasonography