{"?xml":{"@version":"1.0"},"edm:RDF":{"@xmlns:dc":"http://purl.org/dc/elements/1.1/","@xmlns:edm":"http://www.europeana.eu/schemas/edm/","@xmlns:wgs84_pos":"http://www.w3.org/2003/01/geo/wgs84_pos","@xmlns:foaf":"http://xmlns.com/foaf/0.1/","@xmlns:rdaGr2":"http://rdvocab.info/ElementsGr2","@xmlns:oai":"http://www.openarchives.org/OAI/2.0/","@xmlns:owl":"http://www.w3.org/2002/07/owl#","@xmlns:rdf":"http://www.w3.org/1999/02/22-rdf-syntax-ns#","@xmlns:ore":"http://www.openarchives.org/ore/terms/","@xmlns:skos":"http://www.w3.org/2004/02/skos/core#","@xmlns:dcterms":"http://purl.org/dc/terms/","edm:WebResource":[{"@rdf:about":"http://www.dlib.si/stream/URN:NBN:SI:doc-MQP0EO9C/dd9cc73f-66da-41d0-8347-d418ed9544c9/HTML","dcterms:extent":"46 KB"},{"@rdf:about":"http://www.dlib.si/stream/URN:NBN:SI:doc-MQP0EO9C/b5e66be6-761c-4037-b1e7-90edafbaaf25/PDF","dcterms:extent":"233 KB"},{"@rdf:about":"http://www.dlib.si/stream/URN:NBN:SI:doc-MQP0EO9C/ea219fc0-11e1-4cd0-a9a8-749e92cfcf40/TEXT","dcterms:extent":"39 KB"}],"edm:TimeSpan":{"@rdf:about":"1929-2026","edm:begin":{"@xml:lang":"en","#text":"1929"},"edm:end":{"@xml:lang":"en","#text":"2026"}},"edm:ProvidedCHO":{"@rdf:about":"URN:NBN:SI:doc-MQP0EO9C","dcterms:isPartOf":[{"@rdf:resource":"https://www.dlib.si/details/urn:nbn:si:spr-a30mfzkp"},{"@xml:lang":"sl","#text":"Zdravniški vestnik"}],"dcterms:issued":"2004","dc:creator":"Robida, Andrej","dc:format":[{"@xml:lang":"sl","#text":"letnik:73"},{"@xml:lang":"sl","#text":"številka:9"},{"@xml:lang":"sl","#text":"str. 681-687"}],"dc:identifier":["COBISSID:1246693","ISSN:1318-0347","URN:URN:NBN:SI:doc-MQP0EO9C"],"dc:language":"sl","dc:publisher":{"@xml:lang":"sl","#text":"Slovensko zdravniško društvo"},"dc:subject":[{"@xml:lang":"sl","#text":"bolniki"},{"@xml:lang":"en","#text":"health care"},{"@xml:lang":"sl","#text":"medicinske napake"},{"@xml:lang":"sl","#text":"napake"},{"@xml:lang":"sl","#text":"nesreče"},{"@xml:lang":"sl","#text":"nevarni dogodki"},{"@xml:lang":"sl","#text":"vzroki"},{"@xml:lang":"sl","#text":"zdravstvo"}],"dcterms:temporal":{"@rdf:resource":"1929-2026"},"dc:title":{"@xml:lang":"sl","#text":"Opozorilni nevarni dogodki|"},"dc:description":[{"@xml:lang":"sl","#text":"Background. The Objective of the article is a two year statistics on sentinel events in hospitals. Results of a survey on sentinel events and the attitude of hospital leaders and staff are also included. Some recommendations regarding patient safety and the handling of sentinel events are given. Methods. In March 2002 the Ministry of Health introduce a voluntary reporting system on sentinel events in Slovenian hospitals. Sentinel events were analyzed according to the place the event, its content, and root causes. To show results of the first year, a conference for hospital directors and medical directors was organized. A survey was conducted among the participantswith the purpose of gathering information about their view on sentinel events. One hundred questionnaires were distributed. Results. Sentinel events. There were 14 reports of sentinel events in the first year and 7 in the second. In 4 cases reports were received only after written reminders were sent to the responsible persons, in one case no reports were obtained. There were 14 deaths, 5 of these were in-hospital suicides, 6 were due to an adverse event, 3 were unexplained. Events not leading to death were a suicide attempt, a wrong side surgery, a paraplegia after spinal anaesthesia, a fall with a femoral neck fracture, a damage of the spleen in the event of pleural space drainage, inadvertent embolization with absolute alcohol into a femoral artery and a physical attack on a physician by a patient. Analysis of root causes of sentinel events showed that in most cases processes were inadequate. Survey. One quarter of those surveyed did not knowabout the sentinel events reporting system. 16% were having actual problems when reporting events and 47% beleived that there was an attempt to blame individuals. Obstacles in reporting events openly were fear of consequences, moral shame, fear of public disclosure of names of participants in the event and exposure in mass media. The majority of the surveyed persons agreed to disclosure of the event to a patient but this was the case in less than half of the occasions. Conclusions. The small number of reports of sentinel events, late or incomplete reporting of conducted analyses of root causes and plans for future prevention of these events and survey data showed the state of culture in the majority of hospitals. Fear of reporting and therefore, hiding of errors or ascribing errors to the \"usual\" complications of a disease or procedures, the reaction of leadership to quickly find a culprit for the event, disregarding a serious approach to analyze the event and taking measures for their future prevention leads to the culture of silence. Root cause analysis of the events showed that the reason frequently lies in systems and processes and not in individuals. Health care will never be without risks for patients. However, with an open approach without the blaming and shaming of individuals, implementation of reporting the events in hospitals and other health care facilities with clear goals of patient safety,standardization of equipment, materials, and processes and education onpatient safety many sentinel events and medical errors could and should be prevented"},{"@xml:lang":"sl","#text":"Izhodišča. Namen članka je prikazati dvoletne statistične podatke o opozorilnih nevarnih dogodkih (OND) in njihovih vzrokih, prikazati rezultate ankete o teh dogodkih in podati priporočila za zmanjševanje teh dogodkov in drugih zdravstvenih napak. Metode. V marcu 2002 je Ministrstvo za zdravje pričelo z zbiranjem poročil o opozorilnih nevarnih dogodkih v vseh bolnišnicahv Sloveniji. Opozorilne nevarne dogodke smo analizirali po kraju (bolnišnica, dejavnost), po vsebini in po poreklu vzrokov dogodka. Eno leto povzpostavitvi poti poročanja je Ministrstvo za zdravje prikazalo izsledke o opozorilnih nevarnih dogodkih na sestanku direktorjev in strokovnih direktorjev. Istočasno smo razdelili tudi anketo o teh dogodkih, s katero smo želeli ugotovitvi, kaj vodstva bolnišnic in drugi anketiranci menijo o opozorilnih nevarnih dogodkih. Razdelili smo 100 anket in zastavili 15 vprašanj. Vzorec ankete ni bil naključen. Dobili so jo tisti, ki so bili prisotni na srečanju. Rezultati. Opozorilni nevarni dogodki. V prvem letu so bolnišnice poročale o 14 opozorilnih nevarnih dogodkih, v drugem pa o sedmih. V štirih primerih smo zaradi kasnitve prejemanja analiz in ukrepov pisno posredovali in šele nato prejeli ustrezne odgovore, v enem primeru odgovora nibilo. Štirinajst bolnikov je umrlo, 5 od teh jih je naredilo samomor v bolnišnici, pri 6 je prišlo do smrti zaradi škodljivega dogodka, 3 smrti so ostale nepojasnene. Dogodki, ki niso končali s smrtjo so bili poskus samomora,zamenjava strani operacije, paraplegija po spinalnem bloku, padec s postelje in zlom vratu stegnenice, poškodba vranice pri drenaži plevralnega prostora, fizični napad bolnika na zdravnika in zatekanje absolutnega alkoholav femoralno arterijo ob embolizaciji tumorske arterije. Pri analizi porekla vzrokov 21 sporočenih OND smo ugotovili, da so za te dogodke največkrat krivi neizdelani procesi. Anketa. Anketa je pokazala da ena četrtina anketirancev ni seznanjena z načinom poročanja, analize in uvedbe ukrepov ob opozorilnih nevarnih dogodkih. Čeprav je imelo \"le\" 16% anketirancev težave zaradi poročanja, jih je kar 47% menilo, da se je skušala zvreči krivda na posameznika. Pri ugotavljanju ovir za poročanje so vzroki predvsem strah pred posledicami, moralna sramota, strah pred objavo imen udeležencev in vmešavanje medijev. Večina anketirancev meni, da je treba bolniku odkrito povedati kaj se je zgodilo, da pa je to bolniku res sporočeno,zatrjuje manj kot polovica anketiranih. Zaključki. Majhno število sporočenih dogodkov, velikokrat nepravočasno poročanje o napravljenih analizahin ukrepih za preprečevanje OND ali pa nepopolne analize ter nekateri podatki iz ankete kažejo na kulturo vedenja v bolnišnicah. Strah udeležencev pred poročanjem in s tem skrivanje dogodkov ali pripis dogodka \"normalnim\" zapletom bolezni, preiskav ali posegov, hitre reakcije nekaterih vodstev pri iskanju krivca, omalovaževanje pristopa k resni analizi in pripravi načrtov zabodoče preprečevanje vodijo h kulturi molčečnosti. Vzroki dogodkov so pokazali, da so zanje največkrat krivi sistemi in procesi in ne posamezniki. Zdravstvena oskrba nikoli ne bo potekala povsem brez tveganj za bolnika. Vendar se moramo zavedati, da veliko število opozorilnih nevarnih dogodkov in drugih zdravstvenih napak lahko preprečimo z odkritim obravnavanjem, brez sramotenja udeležencev, uvajanjem poročanja v bolnišnicah in drugih zdravstvenih ustanovah, vključevanjem jasnih principov varnosti bolnikov, kot je standardizacija opreme, potrošnega materiala in procesov in vzpostavitvijo izobraževanja varnosti za bolnike"}],"edm:type":"TEXT","dc:type":[{"@xml:lang":"sl","#text":"znanstveno časopisje"},{"@xml:lang":"en","#text":"journals"},{"@rdf:resource":"http://www.wikidata.org/entity/Q361785"}]},"ore:Aggregation":{"@rdf:about":"http://www.dlib.si/?URN=URN:NBN:SI:doc-MQP0EO9C","edm:aggregatedCHO":{"@rdf:resource":"URN:NBN:SI:doc-MQP0EO9C"},"edm:isShownBy":{"@rdf:resource":"http://www.dlib.si/stream/URN:NBN:SI:doc-MQP0EO9C/b5e66be6-761c-4037-b1e7-90edafbaaf25/PDF"},"edm:rights":{"@rdf:resource":"http://creativecommons.org/licenses/by-nc/4.0/"},"edm:provider":"Slovenian National E-content Aggregator","edm:intermediateProvider":{"@xml:lang":"en","#text":"National and University Library of Slovenia"},"edm:dataProvider":{"@xml:lang":"sl","#text":"Slovensko zdravniško društvo"},"edm:object":{"@rdf:resource":"http://www.dlib.si/streamdb/URN:NBN:SI:doc-MQP0EO9C/maxi/edm"},"edm:isShownAt":{"@rdf:resource":"http://www.dlib.si/details/URN:NBN:SI:doc-MQP0EO9C"}}}}