Share Impression

Patient Safety

Article HAS - Mis en ligne le 27 oct. 2015

Patient safety is defined as the reduction of risk of preventable harm to a patient.

Its primary aim is to avoid an undesirable reversal of the risk/benefit ratio throughout treatment.

Adverse events related to care

An adverse event related to care is an unexpected event that disrupts or delays the process of care, or directly affects a patient's health. This event is subsequent to preventive, diagnostic or treatment procedures. It deviates from anticipated results or expectations of care and is unrelated to the natural course of disease.

  • Adverse events can be serious (SAE), such as an unexpected death, a serious life-threatening complication or permanent loss of function not resulting from the natural course of disease.
  • They can also be inconsequential if detected and successfully treated in time. This is called a "near-miss" or risk event for which the analysis can provide as much information as an SAE.

Causes of adverse events

The cause of these adverse events is seldom related to a lack of professional knowledge (see: To Err is Human: Building a Safer Health System, a report from the U.S. Institute of Medicine). These adverse events are most often caused by:

  • organisational flaws
  • lack of verification
  • lack of coordination
  • lack of communication

In short, they are often due to a lack of a common knowledge about safety and teamwork.

Numerous publications stress the significance of risks associated with patient care and their lack of proper control: adverse events related to care continue to remain a frequent occurrence.

The French National Surveys on Adverse Events Related to Care (ENEIS) conducted in 2005 and 2009 show:

  • a stable rate of about 1 serious adverse event every 5 days per 30-bed section,
  • 4.5% of healthcare facility admissions are the result of a serious adverse event.

Finally, a 2011 survey by IRDES [French Institute for Research and Documentation in Health Economics] estimates the cost of SAEs in France to be 700 million EUR for 2007 alone.

Aware of the public health stakes and concerns, France established a National Patient Safety Programme (PNSP) in 2013. The areas developed within this programme place the patient at the heart of both the programme and the health care team. By emphasising on the culture of safety, training, communication and the reporting of adverse events, the programme touches on all aspects affecting patient safety.