Provide support and management solutions to companies committed to provide high standard services to its customers.
- Cooperate with companies and institutions seeking management solutions that can optimize their operation and profitability.
- Organize information for the correct diagnosis of management problems and plan a constant system restructuring.
- Always seek the highest standard of quality and safety for the customer.
Regardless of the Country , the Health System is considered a complex one due to the interaction of numerous factors on patient care. In addition to individual factors , it is observed third-party influences, such as doctors and nurses, internal organizational policies, macro-economic and social characteristics, among others.
Adverse event can be defined as unintentional physical damage caused or contributed for health care that requires monitoring, treatment or additional hospitalization or resulting in death. It is worth noting that patients may experience adverse effects from their treatment, without having been victim of an error1. Error is defined in the literature as an act of commission or omission, leading to an undesirable outcome or potential of this2. Many errors do not result in adverse events.
Analyzing the sequence of steps that characterize the patient care, potential protective barriers could be arranged to avoid harm to the patient in the presence of a system failure.
As a result of the analysis of these faults, proposed simplification and standardization procedures can be proposed, creating redundant mechanisms that provide opportunities for backup and recovery, improvement of communication between different groups, among other changings, in order to protect patients.
The paradigm of trying to improve human behavior to perfectionism is broken up and it is given more attention to the decrease in the incidence of latent errors and creating multiple protective barriers.
There are numerous studies conducted in different countries on adverse events in which we can observe some consistent factors:
- All ages are exposed.
- Incidents and adverse events are not restricted to hospitals and can occur anywhere where it carries out health care.
- Statistics are at least worrisome.
- Incidents and adverse events are underreported, even in developed countries.
Patients and health institutions benefit from this cultural shift from a previously punitive system, where it sought to find guilty to one that seeks to correct flaws , considering patient care a logical sequence of steps. From the notifications received, the Managers may restructure health systems, making them safer.
1. Bates DW, Leape LL. Adverse drug reactions. In: Carruthers SG, et al. Eds. Clinical Pharmacology. New York, McGraw-Hill: 2000
2. DW in Bates al. Incidence of adverse drug events and adverse drug events potential. Journal of the American Medical Association 1995, 274: 29-34