Current trends in examination of undesirable events in the health service system

Abstract

Fakultní nemocnice Ostrava, Interní klinika Ostravská univerzita, Zdravotně sociální fakulta, Ústav fyziologie a patofyziologie Summary The main target of examination of failures in providing the health care is prevention of repeating undesirable events. Two approaches are possible in the examination of failures: personal and systemic approaches, where each of them employs a different method and presents different starting points for the solution of the failure. Understanding of differences between the two approaches mentioned is of a considerable practical importance. The more frequently used personal approach puts emphasize on the failure itself and the systemic approach is focused on formation of protective barriers against all the risks in providing the health care. Most failures in providing the health care have their individual and institutional levels. The failure is usually caused by a non-standard procedure performed by a healthcare professional on the one hand, and by supporting factors on the other. In the course of the examination, the damaged patient should be provided with an extraordinary and complex care, but the specific support of relevant healthcare professionals can also be necessary. The systemic approach to solving undesirable events is ethically more advantageous from the standpoint of patients as well as healthcare professionals and management since it offers a complex prevention of repeating the failure.