Los sistemas de registro y notificación de efectos adversos y de incidentes: Una estrategia para aprender de los errores

The need to find strategies of error prevention and promotion of patient safety has stimulated countries to develop models that improve knowledge of adverse events. One of the tools used are reporting systems for gathering information about errors. To review existing reporting systems, to describe the models developed by the countries with the longest tradition in designing strategies for the promotion of patient safety and prevention of adverse events and to determine the factors required for the development of future reporting systems. Adverse event reporting systems were created in nonmedical fields, with the aim of collecting information relating to near-misses (without harm) or accidents (with harm). This information was used to establish a profile of the most frequent problems in an organization and to understand the factors that contribute to errors. There are different types of reporting systems. Nevertheless, independently of the reporting system used, their application and development benefits the organization since they generate opportunities for modeling events, monitoring, increasing awareness of safety problems and more efficient resource use. New strategies should be designed to increase health professionals' commitment to reporting adverse events. Legal and organizational barriers that hamper their implementation should be analyzed.