Notification of adverse events and characterization of the triggering factors in the pediatric surgery unit

Imagem de Miniatura
Arquivos
art_SILVA_Notification_of_adverse_events_and_characterization_of_the_2018.PDF (188.3 KB)
Citações na Scopus
1
Tipo de produção
article
Data de publicação
2018
Editora
CENTRO UNIV SAO CAMILO
DOI
Indexadores
Scopus
Web of Science
Título da Revista
ISSN da Revista
Título do Volume
Autores
ARAUJO, Viviane Ferreira de
FELDMAN, Liliane Bauer
Autor de Grupo de pesquisa
Editores
Coordenadores
Organizadores
Citação
MUNDO DA SAUDE, v.42, n.2, p.349-358, 2018
Projetos de Pesquisa
Unidades Organizacionais
Fascículo
Resumo
The study aimed to identify the incident-adverse events reported in a surgical pediatric unit and characterize triggering factors. This is a retrospective field study, with a documentary and descriptive quantitative approach, developed at the Pediatric Public Hospital in Sao Paulo, and data were collected for twelve months in 2015. 142 adverse events-incidents were identified related to skin lesions, loss of central venous catheter, loss of nasogastric, enteral and gastrostomy tube, fall, administration of medication, drainage loss, loss of epidural catheter and phlebitis, resulting in mild damage in infants. The triggering factors were: inadequate fixation of peripheral venous access, serum infiltration, use of inappropriate adhesive tape; leakage, disconnection, rupture or breakage of the central venous catheter; accidental removal of the tube, cracks; deflated balloon; medication not available, lack of attention or error, lack of training; recklessness; ineffective communication; divergence in the standard operating procedure and late material replenishment process. It was concluded that the nurse was the professional who stood out in the identification and notification of the event, that the multiprofessional team and the patient-family should be encouraged to notify them, and that the detailed notifications generate preventive actions and strategies.
Palavras-chave
Adverse events, Patient safety, Nursing, Pediatric nursing
URI
https://observatorio.fm.usp.br/handle/OPI/29628
Referências
  1. Anvisa (Brasil), 2016, SEG PAC QUAL SERV SA
  2. Anvisa (Brasil), 2011, B INF SEG PAC QUAL S
  3. Beccaria Lucia Marinilza, 2009, Rev. bras. ter. intensiva, V21, P276, DOI 10.1590/S0103-507X2009000300007
  4. de Paiva MCMD, 2010, REV ESC ENFERM USP, V44, P286, DOI 10.1590/S0080-62342010000200007
  5. de Moura Gisela Maria Schebela Souto, 2009, Rev Gaucha Enferm, V30, P136
  6. Feldman LB, 2017, US SEG MED GUIA PREP
  7. Duarte SDM, 2015, REV BRAS ENFERM, V68, P136, DOI 10.1590/0034-7167.2015680120p
  8. de Paiva MCMD, 2014, REV LAT-AM ENFERM, V22, P747, DOI 10.1590/0104-1169.3556.2476
  9. Pereira Rocha Judite, 2014, Cienc. enferm., V20, P53, DOI 10.4067/S0717-95532014000200006
  10. Nascimento CCP, 2008, REV LAT-AM ENFERM, V16, P746, DOI 10.1590/S0104-11692008000400015
  11. Ruppenthal JE, 2013, GERENCIAMENTO RISCOS
  12. Silva AEBC, 2010, REV ELETR ENFERM, V12, P422
  13. Silva LA, 2014, REV ENFERM UFPE LINE, V8, P3015
  14. World Health Organization, 2009, CONC FRAM INT CLASS
  15. Xavier-Gomes LM, 2013, MUNDO SAUDE, V37, P394

Coleções
Artigos e Materiais de Revistas Científicas - HC/ICESP