Patient safety and adverse events

System and programme

Patient safety aims to cut the harm caused by care itself: recognise failures, report them without blame and put barriers in place.

Updated Nov 13, 2026

Key points

Incident: a failure in care that caused no harm; adverse event: a result of care that unintentionally caused harm.
Preventable adverse event: would have been avoided by meeting available standards of care; non-preventable: happens despite meeting them.
Policy principles: user-centred care, a safety culture of confidentiality and trust, integration with the SOGCS, multicausality, validity, and alliance with the patient and with the professional.
Systems approach: active failures (by those giving care) and latent failures (in support processes and the organisation) usually combine.
The London Protocol analyses contributory factors (patient, task, individual, team, environment, organisation) instead of looking for someone to blame.
WHO: falls are the most frequent adverse event in hospitals, and medication errors affect about 1 in 30 patients.

What it is

In Colombia, patient safety is the set of structural elements, processes, tools and evidence-based methods that aim to minimise the risk of an adverse event during care or to mitigate its consequences. The national policy, with Ministry guidelines from 2008, is an integral, cross-cutting part of the SOGCS. According to WHO, about 1 in 10 patients is harmed in health care and more than half of that harm is preventable.

How it is organised

Identify: voluntary reporting, safety rounds, record review and indicators.
Report: in a climate of confidentiality and trust; the aim is to learn, not to punish.
Analyse: classify the case (incident or adverse event, preventable or not) and look for causes with a structured method.
Act: safety barriers and risk-reduction actions, proactive (failure mode analysis) or reactive (root cause analysis).
Measure: indicators from the information system for quality.

Worked example

A made-up internal medicine ward logs 6 000 bed-days in six months.
21 falls are reported; 7 caused injury.
Fall rate = 21 / 6 000 × 1 000 = 3.5 per 1 000 bed-days.
With injury: 7 / 21 ≈ 33% (rounded); those are adverse events, the rest are incidents.
A London Protocol analysis finds wet floors at night, call bells out of reach and sedated patients without a companion.
With barriers (bell within reach, signposted bathrooms, fall-risk check on admission), the next six months bring 9 falls in 6 000 bed-days: 1.5 per 1 000.
Reading: the rate fell from 3.5 to 1.5 per 1 000 bed-days; the system was fixed and no one was blamed.

Classifying what happened

Term	Harm?	Example
Sign of unsafe care	No; it is a warning	Two patients with the same surname in neighbouring rooms
Incident	No	A medicine is prepared for the wrong patient and caught before it is given
Preventable adverse event	Yes	Pressure ulcer in a patient who was not repositioned
Non-preventable adverse event	Yes	Severe allergic reaction to a medicine at first use, with no known history

Markers

Incident
Adverse event
London Protocol
Safety barrier
SOGCS

In practice

Routine safe practices: identify the patient with two identifiers, hand hygiene, surgical safety checklist, medication reconciliation, and prevention of falls and pressure ulcers.
Patients and families are allies: they are told what happened and involved in improvement actions.
An incident without harm (a near miss) is also reported: it reveals the failure before it hurts someone.

Reference norms

Guidelines for implementing the Patient Safety Policy in the Republic of Colombia (Ministry of Social Protection, 2008).
Decree 780 of 2016 (compiling Decree 1011 of 2006): safety is one of the five characteristics of the SOGCS.
Technical guide ‘Good practices for patient safety in health care’ (Ministry, 2010) and its training packages.

Test yourself

Think of the answer, then tap the question to see it.

What is the difference between an incident and an adverse event?

An incident is a failure in care that caused no harm; an adverse event is an unintended result of care that did cause harm.

When is an adverse event preventable?

When it would have been avoided by meeting the standards of care available at the time.

What does the London Protocol look for?

The contributory factors behind an incident or adverse event (patient, task, individual, team, environment and organisation) rather than someone to blame.

How does patient safety relate to the SOGCS?

Safety is one of the five characteristics of the SOGCS, and the patient safety policy cuts across all its components.

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Connections

← All of epidemiology

Educational content on epidemiological and statistical methods; the examples use made-up numbers to teach the calculation. Not a clinical or legal guide: current Colombian rules are in the official sources.

Sources: Lineamientos para la implementación de la Política de Seguridad del Paciente en la República de Colombia (Ministerio de la Protección Social, Colombia, 2008); Seguridad del paciente (Ministerio de Salud y Protección Social, Colombia, 2026); Patient safety (World Health Organization, 2023); Decreto 780 de 2016 Sector Salud y Protección Social (Departamento Administrativo de la Función Pública, Colombia (Gestor Normativo), 2016).

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Representative model, for educational purposes only.