Results of the project

This section will publish some of the results from our study as we reach each of the established objetives.

Results of the survey given to hospital and primary care professionals

  • Only 20% of centers have defined who must inform a patient following an adverse event.
  • Only 18% of professionals have received training on correctly informing patients after adverse events.
  • The impact of adverse events on professionals: as much as 2% leave the profession.
  • Following an adverse event, it is more likely that patients receive an apology at a hospital than in primary care.
  • Care protocols for second victims of adverse events exist at 10% of hospitals and 7% of primary care areas.
  • 19% of hospitals and 22% of primary care areas do not have a plan for annual training on patient safety.
  • After being informed about an adverse event, 40% of hospital patients and 30% of primary care patients file claims.
  • A sense of guilt, anxiety, reliving adverse events are the most frequent symptoms in second victims in Spain.

Learn more about the results of our study by consulting the following papers: Mira JJ, Carrillo I, Lorenzo S, Ferrús L, Silvestre C, Pérez-Pérez P, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Services Research 2015, 15:151. doi: 10.1186/s12913-015-0790-7

Lena F, Silvestre C, Guadalupe O, Mira JJ. Qualitative study about the experiences of colleagues of health professionals involved in an adverse event . J Patient Saf. 2016.

Results of the survey given to managers and coordinators of patient safety at hospitals and primary care

  • Nineteen (16.5%) hospitals and 7 (5.3%) health areas reported to have implemented a crisis plan.
  • Only 2 (1.7%) hospitals and 1 (0.8%) health area had an action plan implemented to support second victims.
  • Three (2.6%) hospitals and 4 (3%) health areas claimed to be prepared to deal with the repercussions from adverse events.
  • Health coordinators considered to be more useful than did managers that the voluntary notification rate of AE be analyzed periodically and that patients who suffered an adverse event participate in a root cause analysis.

Further information is available at: Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Pérez P, Iglesias F, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims . BMC Health Services Research. 2015. 15:341.

Mira JJ, Carrillo I, Lorenzo S. Qué hacen los hospitales y la atención primaria para mitigar el impacto social de los eventos adversos graves . Gac Sanit. 2017;31:150-3.

Publications on Open Disclosure in Spain

Only 28% of managers at hospitals and primary care and 36% of professionals consider that their centers correctly inform patients who suffer an AE. Both groups admit that they do not know who should inform the patient, that it is not common for patients who suffer an adverse event to have a channel open during the subsequent weeks for resolving doubts and being able to inform about any complications, and that there are significant shortcomings when it comes to planning, organizing, and ensuring that the patient who suffers an adverse event receives an apology and frank information about what exactly happened, and what might happen from that moment forward.

More at: Mira JJ, Lorenzo S, en nombre del Grupo de Investigación en Segundas Víctimas. Algo no estamos haciendo bien cuando informamos a los/las pacientes tras un evento adverso . Gac Sanit. 2015;29(5):370-4. doi: 10.1016/j.gaceta.2015.04.004

Mira JJ, Ferrús L, Silvestre C, Olivera G. Estudio cualitativo sobre qué, quién, cuándo, dónde y cómo informar a los pacientes tras un evento adverso . Enferm Clin. 2017;27:87-93.

A working meeting was held in July 2016 wherein experts on quality and safety as well as jurists from different Spanish institutions participated with the objective of producing a set of recommendations on how to present an apology to a patient who suffered an AE. The document that resulted from the consensus in said meeting can be consulted here.

Mira JJ, Romeo Casabona CM, Astier MP, Urruela Mora A, Carrillo I, Lorenzo S, et al. Si ocurrió un evento adverso piense en decir “lo siento” . An Sist Sanit Navar. 2017;40:279-90.

Mira JJ, Romeo-Casabona CM, Urruela-Mora A, Agra Y, Astier P, Lorenzo S, et al. La seguridad jurídica de los profesionales sanitarios. Un requisito para lograr una mayor calidad asistencial. Derecho y Salud. 2017;27:94-110.

Other publications