Recommendations

It should be considered that while adverse events are the flip side of the patient safety coin, the management of the risks inherent in healthcare is the desirable goal and therefore an integral part of good clinical practice.

This opens the way for the concept of resilience in healthcare organisations, understood as the degree to which a system prevents, detects, mitigates, or ameliorates hazards or incidents, enabling an organisation to “recover” as quickly as possible to its original ability to perform care functions after harm has occurred. Achieving this requires an appropriate environment.

Although in practice we accept that adverse events may occur for several causes, we do not accept that these incidents occur repeatedly for the same reasons.

When an adverse event occurs, like any other critical situation, different focal points require attention and timely response. The comprehensive management of adverse events and their impact requires the almost simultaneous approach of the multiple agents and levels affected (patient and family, healthcare professionals, institution). It implies tasks such as incident notification and analysis, frank communication with the first victim, or crisis communication if the adverse event has a media impact.

The next pages present a set of recommendations that guide the analysis of the incident, the communication of what happened to the patient or their family, and the protection of the reputation of the healthcare institution and the professionals.