Patient safety in Colombia: the policy and its instructional packages
- Fundamental
Colombia has a national policy to reduce avoidable harm from health care and to learn from errors without looking for someone to blame.
What it is
The Patient Safety Policy is part of Colombia's Mandatory System for Quality Assurance in Health Care (SOGC). In 2008 the Ministry of Social Protection (now MinSalud) issued the «Guidelines for implementing the Patient Safety Policy», which set its principles, its objectives and a shared vocabulary (incident, adverse event, safety barrier and others). In 2010 the «Technical guide: Good practices for patient safety in health care» was approved; it gathers the recommended safe practices, and the instructional packages are training modules that help bring each practice into an institution's own processes. The model used to explain adverse events is the Swiss cheese model: harm happens when failures in several layers of the system line up.
Key points
- The policy aims to prevent situations that affect patient safety and to reduce, and where possible eliminate, adverse events.
- It is an integral part of the SOGC and cuts across all of its components.
- Safety problems are seen as systemic and multi-causal, not as isolated failures of one person.
- A safety barrier is any action or circumstance that lowers the probability of an incident or an adverse event.
- Safety violations are deliberate departures from a rule; failures, by definition, are unintentional.
- Adverse events are analysed with methods such as the London Protocol, root cause analysis and failure mode and effects analysis (FMEA).
Components
- Seven guiding principles: user-centred care, safety culture, integration with the SOGC, multi-causality, validity (evidence-based methods), alliance with the patient and family, and alliance with the health professional.
- Objectives: steer institutional policies towards safe care, lower risk, prevent adverse events, coordinate the actors, unify terminology and educate patients and families.
- Institutional patient safety programme: its own policy, promotion of a safety culture, a reporting and learning system, and analysis and management of events.
- Good practices in four groups: safe institutional processes, safe care processes, practices that improve professionals' performance, and involvement of patients and their families.
- Instructional packages: training modules for each practice (for example fall prevention, pressure ulcers, patient identification, safe surgery, safety culture), published by the Ministry to bring each recommendation into internal processes.
What it is for
- Gives the whole country the same definitions, so a report means the same thing in any institution.
- Turns international evidence into concrete recommendations for Colombian institutions.
- Provides tools to identify, report, analyse and prevent adverse events.
- Protects both the patient and the professional: the focus is on improving processes, not on punishment.
Key terms from the Guidelines (in our own words)
| Term | What it means | Teaching example |
|---|---|---|
| Sign of unsafe care | A sign or circumstance warning that the risk of an incident or adverse event has risen | Return to the emergency department for the same cause a few days after discharge |
| Incident | There was a failure in the care process, but the patient was not harmed | A medicine is prepared for the wrong patient and the error is caught before it is given |
| Preventable adverse event | Unintended harm that would have been avoided by meeting the available standards of care | A pressure injury in a high-risk patient who was not repositioned |
| Non-preventable adverse event | Unintended harm that happens even though the standards of care were met | A severe allergic reaction to a medicine in a patient with no known history |
| Complication | Unexpected harm or outcome due to the disease or the patient's own condition, not to the care | Expected progression of a severe infection despite correct treatment |
In nursing practice
- Nursing is present around the clock and applies many barriers: identification, hand hygiene, fall and pressure injury prevention.
- Reporting an incident or an adverse event is part of the job, following your institution's procedure.
- The patient and family are allies: explain the risks to them and encourage them to ask questions.
- Taking part in safety rounds and case analyses helps redesign unsafe processes.
Common mistakes
- Confusing an incident (no harm) with an adverse event (harm).
- Calling a harm a complication when it was actually caused by the care.
- Thinking the purpose of reporting is to find the culprit.
- Not reporting incidents because «nothing happened»: they are the best source of learning.
- Seeing the policy as paperwork rather than a change of culture.
Test yourself
Think of the answer, then tap the question to see it.
What is the difference between an incident and an adverse event?
Both involve a failure of care, but in an incident the patient is not harmed, while an adverse event does cause unintended harm.
In what year did the Ministry of Social Protection issue the Guidelines for implementing the Patient Safety Policy?
In 2008. The Technical guide of good practices for patient safety was approved later, in 2010.
Which model do the Guidelines use to explain how an adverse event happens?
The Swiss cheese model: harm happens when failures in different processes or barriers of the system line up.
What is a safety barrier?
An action or circumstance that lowers the probability of an incident or an adverse event, such as checking two identifiers before a procedure.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Lineamientos para la implementación de la Política de Seguridad del Paciente (Ministerio de la Protección Social (MinSalud), Colombia, 2008); Guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud, versión 1 (Ministerio de la Protección Social (MinSalud), Colombia, 2010); Paquetes instruccionales: Promoción de la cultura de seguridad del paciente (Ministerio de la Protección Social (MinSalud), Colombia, 2010).
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Representative model, for educational purposes only.