Indicadores de resultados para la asistencia: Análisis de situaciones adversas durante la hospitalización

Abstract

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 São 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.