Process evaluation of a Surveillance Program of Adverse Hospital Events: Davila Clinic, Chile

Abstract

Objective: Evaluate the implementation process of a surveillance program for adverse events in a private hospital in Chile (Clínica Dávila). Materials and Methods: A case study methodology was used, using a framework for analysis based on the recommendations of international organizations, and integrating qualitative and quantitative techniques for gathering and analyzing data.Results: A high level of coherence was found between program design and the analysis framework.

An increase in the notification rate, both for the administration of the wrong medication and for falls was also noted (58% among both), those being the principal motivations for root cause analysis (RCA). 43.8% of causes were identified as individual factors and only 15.73% as institutional or organizational factors. Interviewees valued the program and believe that it created a good learning environment, but they propose better feedback and management, and building competency for error analysis in clinical processes. Conclusions: The program contributed to a better learning environment, but there was an imbalance between the data collection efforts and systematic data analysis. The voluntary and anonymous notification system has been transformed into a space for communication within the hospital, which exceeded the program's objectives and should be taken into account in the implementation of similar programs.