“The method of black spots” in risk management of adverse events – with the example of a research hospital
Keywords:
risk management, method of black spots, identify of adverse events, the significance levels of black spotsAbstract
Introduction. Health Care Centres are institutions which, because of their specificity and character, are particularly exposed to various kinds of risk. One of the most important and most frequently used methods of risk management is a method of black spots.
Aim. The aim of this research was to develop the basis for creating a model of medical procedures and interventions which are subject to monitoring regarding risk management in various wards of a hospital.
Material and methods. The presented research material comes from one of the university hospitals in Łódź Province. The information was gathered basing on 450 complete medical histories and other medical documentation of patients treated in the hospital between 2006-2007. The analysis covered random chosen stays in the Dialysis Centre and hospitalization in the Ophthalmology Ward, Neurosurgery Ward and Plastic Surgery Ward.
Results. All gathered data made it possible not only to determine complications which occurred during the provision of the aforementioned medical benefits but also to propose possible preventive or corrective activities. Simultaneously, based on the analyzed documentation, the mean hospitalization time (with no complications) was determined for each surgery/treatment as well as the frequency of separate adverse events and the mean hospitalization time for each separate complication. The approximate cost of person-day was also estimated for chosen clinics.
Conclusion. Each adverse effect or event has its specific causes. Recognizing them, i.e. precisely determining the aetiology, is a very important and primary aspect in the whole process of risk management. The analysis of occurring complications or hazards, even those that seem the least important, is a chance of limiting them or even completely eliminating them.
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