Indicators of healthcare results:: Analysis of adverse events during hospital stays

被引:36
|
作者
Pires Nascimento, Camila Cristina [1 ]
Toffoletto, Maria Cecilia [2 ]
Goncalves, Leilane Andrade [2 ]
Freitas, Walkiria das Gracas [3 ]
Padilha, Katia Grillo [2 ]
机构
[1] Hosp Alemao Oswaldo Cruz, Sao Paulo, Brazil
[2] Univ Sao Paulo, Sch Nursing, BR-05508 Sao Paulo, Brazil
[3] Hosp 9 Julho, Sao Paulo, Brazil
来源
关键词
sentinel surveillance; nursing; indicators;
D O I
10.1590/S0104-11692008000400015
中图分类号
R47 [护理学];
学科分类号
1011 ;
摘要
This quantitative, retrospective study aimed to characterize adverse events (AE) in Intensive Care Units (ICU), Semi-Intensive Care Units (SCU) and Inpatient Units (IU), regarding nature, type, day of the week and nursing professionals / patient ratio at the moment of occurrence; as well as to identify nursing interventions after the event and AE rates. The study was performed at a private hospital in the city of Sao Paulo, Brazil. Two hundred twenty-nine AE were notified. The predominant events were related to nasogastric tubes (NGT) (57.6%), followed by patient fall (16.6%) and medication errors (14.8%). The nursing professionals/patient ratio at the moment of the event was 1:2 for the ICU, 1:3 for the SCU and 1:4 for the IU, A similar distribution was observed for the other days of the week. The nursing interventions were: repositioning the NGT (83.2%) and communication of the occurrence to the physician in case of medication errors (47.6%) and falls (55.2%). The highest AE rate was related to NGT.
引用
收藏
页码:746 / 751
页数:6
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