Modern principles of management of patient safety (systematic review)

• Main Author: Y. E. Voskanyan
• Format: Article
• Language: Russian
• Published: Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University) 2018-09-01
• Series: Сеченовский вестник
• Subjects: medical care; patient safety; adverse event; incident; actual threats (actual failures); latent threats (latent failures); medical errors
• Online Access: https://www.sechenovmedj.com/jour/article/view/67

The article analyzes the research works devoted to the study of principles of management of patient safety. Used medical databases MEDLINE, Cochrane Collaboration, EMBASE, SCOPE, ISI Web of Science for the period 1991-2017. In most studies a strict sequence of origin of the harm associated with healthcare management (adverse event or unintended injury), which is based on constant system of causes - latent threats, is shown. The development of an adverse event begins with the activation of the latent threat and turning it into an active threat of group 1 (dangerous situation), which is the cause of the active threats of group 2 (errors and failures). Active threats of group 2 lead to dangerous events (incidents), which are a potential or real cause of unintended injury. Latent and active threats exist on three levels - personnel, environment and patient. Management of latent threats at all levels is at the heart of patient safety, reducing the frequency and severity of unintended injury.