Multifactorial model of adverse events and medical safety management

Abstract

The article describes a multifactorial model of adverse events related to the provision of medical care. It is shown that their origin is caused by the transformation of systemic causes (latent failures) acting at the level of medical organization, external microenvironment and macro-factors. Four types of global latent failures are described at the level of a medical organization related to: medical technology, work of medical personnel, work environment, and patient behavior. At the external microenvironment level, major latent threats are concentrated at the level of partners, suppliers and outsourcers. Among macro-factors influencing medical care safety especially important are the legal factors defining the status of medical errors and their consequences; economic model of state health care; financial provision of state guarantees and rationing of these volumes in regions and municipalities; availability of state medical care safety management programs; state regulation of medical activity; system of pre- and post-graduate medical education; system of labor regulation and remuneration of medical workers; society's attitude towards medical errors and its participation in the process of medical care safety management. The authors present an algorithm for implementation of a safety management system in a medical organization, including the construction of a new safety culture, an accounting system for recording of threats and incidents, a model for managing medical care safety built into the operational system of the organization.