Estimados Académicos FEN,

Los invitamos al Seminario Interno FEN que dictará la académica Alicia Nuñez.

Título: Priorities and Root Cause Analysis for Quality and Safety Problems in Chilean Hospitals  

Background: Public and private efforts have consistently targeted clinical quality and safety problems for more than 20 years, however, medical errors are still one of the leading causes of death in the world. Even though there is extensive scientific and empirical evidence of such problems worldwide; Latin American, and particularly Chile, show a lack of studies on this topic. 

Objective: To prioritize clinical quality and safety problems according to their severity, frequency and detectability in Chilean hospitals. 

Methods: We conducted an exploratory study using an online survey to identify the severity, frequency and detectability of the main clinical quality and safety problems in Chilean hospitals. The risk priority number was computed to rank these problems. This survey was filled by quality directors from 94 hospitals. Based on the results of this survey, we conducted a focus group to find the root causes of the clinical quality and safety problem with the highest risk priority number of the sample. 

Results: In Chile, the three highest priorities for hospitals in terms of their risk were: (1) ineffective interprofessional communication, (2) lack of leadership in addressing frequently recurring safety issues, and (3) antimicrobial resistance due to inappropriate use of antibiotics. For the communication problem the focus group showed two main categories for the root causes, those related to the professionals and those related to the hospitals. 

Conclusions: Hospitals can systematically use this approach to categorize their main clinical quality and safety problems, to analyze their causes and then design solutions for continuous improvement.