According to a report by the High Authority for Health, 820 serious medical accidents were declared in 2018 by health professionals. Declarations still “too timid” despite their mandatory nature since 2017.
In 2018, 820 serious adverse events associated with healthcare (AEGS) were reported to the Haute Autorité de santé (HAS), according to a report released in early December.
Depending on the consequences it has for the person, an adverse event that can occur at any time during this care can be qualified as a serious adverse event associated with treatment (SIGS). This is the case, specifies the HAS, when it creates a permanent functional deficit, the risk of vital prognosis or the death of the patient, i.e. the situation given for half of the medical accidents recorded for the year 2018. elsewhere, the vital prognosis was put into play in 33% of the cases, and 17% of the victims suffered from a “probable permanent functional deficit”.
Serious accidents that take place during “vulnerable periods”
How were these EIGS counted? Since 2017, health professionals have had the obligation to report them to the Regional Health Agencies (ARS), which then send them back to the HAS. In total, 3,536 declarations initiated by health professionals to the ARS were made and 820 were qualified as EIGS. Most come from professionals working in a health establishment (82%), then in the medico-social sector (14%) and finally in the city (4%).
Analysis of the declarations made shows that these serious events occur during vulnerable periods: 39% of declarations thus concern an event that took place at night, on the weekend or on a public holiday, and 55% of them are also considered avoidable.
The three main risks identified are patient suicides (181 cases), lack of care (delay in care, lack of monitoring: 134 cases) and patient falls (121 cases). This is followed by medication errors, unexplained deaths, post-operative complications, false routes and swallowing disorders, poorly controlled passive physical restraints, traumatic gestures and finally SAMU/SMUR interventions.
Finally, some regions are more affected than others: this is the case of Auvergne-Rhône-Alpes (129 cases), Île-de-France (175) and New Aquitaine (123).
A census system to be optimized
If the HAS has managed to draw up a balance sheet of medical accidents, it regrets however that “two obstacles to optimal operation of the device” persist. First, a “still significant under-declaration of EIGS which directly affects the content of the work of the HAS”, but also a “non-maturity of the system characterized by declarations of unequal quality and sometimes incomplete analyzes”.
“This may be due to a still insufficient knowledge of the device, but also to a fear of declaration on the part of health professionals, for fear of the sanction. We must put an end to this culture of blame”, advances on the site of the Figaro Dominique Le Guludec, President of the HAS.
The HAS therefore proposes “to optimize the IT process for SAE declarations” by reinforcing information on the device for healthcare professionals, by developing a “pedagogical guide on the in-depth analysis of SAEs before transmission to HAS ” and finally to carry out “in health and medico-social organizations an audit of the system for reporting adverse events associated with care (including EIGS) and the implementation of corresponding improvement actions.”
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