Analyse des événements indésirables liés à la prestation des soins de santé : Démarche structurée et grille d'analyse

This report defines a framework to evaluate and collect data on incidents and accidents occurring in hospitals and to create database at local and national level. Our goals are: 1) to provide a structure for thorough analysis within the hospitals that can be used with the already existing tools and 2) to standardise data collected on undesirable events, their causes, contextual factors, and the management of the situation. We propose a step by step method to conduct a thorough investigation and we propose an analysis grid (named "Grille d'analyse CIRANO""), based on a model used in the nuclear industry which has been validated by numerous studies, to identify vulnerabilities of the system. This grid can be used as a commune base in hospitals in order to have a minimum standardisation of local database. We are currently working on adapting this grid to other types of health care facilities (CLSC, CHSLD, ?).

The complete version of this publication is confidential."

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