Adverse events related to pratical assistence: an integrative review
Supporting Agencies
- Nenhuma
Abstract
Objective: To identify the scientific publications about adverse events related to practical assistance and discuss the culture of patient safety.Methods: An integrative literature review was done through research in MEDLINE, LILACS and BDENF available in BVS, using the following descriptors: patient safety, patient assistance, surveillance of sentinel event, safety management. 26 scientific articles published in the period defined for this review, 2005 to 2015 met the inclusion criteria.
Results: The analysis of the articles revealed five major categories: characteristics of adverse events related to practical assistance, adverse events occurrence implications, measures for the prevention of adverse events, notifications of adverse events and the intervenient factors and the knowledge and the culture of safety.
Conclusion: The punitive culture comes as responsible for underreporting and omission of adverse events, being constituted a barrier to effective implementation of investigations. It is essential to foster a safety culture to establish strategies that ensure the care provision free of damage.
Downloads
References
Kohn LT, Corrigan JM, Donaldson MS (eds.). To err is human: building a safer health system. Institute of Medicine, Washington: National Academy Press; 2000. 536 p.
Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002;288(4):501-7.
Ministério da Saúde (BR), Agencia Nacional de Vigilancia Sanitária. Estratégias para segurança do paciente em hospitais e clinicas. Brasília (DF): Ministério da Saúde; 2010.
Ministério da Saúde (BR). Portaria nº. 529, de 1 de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP). Diário Oficial da União 1 abr 2013. Brasília (DF): Ministério da Saúde; 2013.
Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada - RDC nº. 36, de 25 de julho de 2013. Institui ações para a segurança do paciente em serviços de saúde e da outras providências. Diário Oficial da União, 2013. Brasília (DF): Ministério da Saúde; 2013.
Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care. 2009;21(4):279-84.
Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-84.
Daud-Gallotti R, Novaes HMD, Lorenzi MC, Eluf Neto J, Okamura MN, Pizzo VRP. Adverse events in patients with community-acquired pneumonia at an academic tertiary emergency department. Infect Dis Clin Pract. 2006;14:350-9.
Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-700.
Forster AJ, Kyeremanteg K, Hooper J, Shojania KG, Van Walraven C. The impact of adverse events in the intensive care unit on hospital mortality and length of stay. BMC Health Serv Res. 2008;8:259.
World Health Organization (WHO). Patient safety research: introductory course - Session 1. What is patient safety? [place unknown]. [internet] WHO; 2012 [acesso 15 jul 2015]. Disponível em: http://www.who.int/patientsafety/research/online_course/en/.
Coli RCP, Anjos MF, Pereira LL. The atitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics. Rev. Latino-Am. Enfermagem. 2010;18(3):324-30.
Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm. 2008;17(4):758-64.
Duarte SCM, Stipp MAC, Silva MM, Oliveira FT. Eventos adversos e segurança na assistência de enfermagem. Rev Bras Enferm. 2015 jan-fev;68(1):144-54.
Novaretti MCZ, Santos EV, Quitério LM, Daud-Gallotti RM. Sobrecarga de trabalho da Enfermagem e incidentes e eventos adversos em pacientes internados em UTI. Rev Bras Enferm. 2014 set-out;67(5):692-9.
Burström L, Letterstål A, Engström ML, Berglund A, Enlund M. The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study. BMC Health Services Research. 2014;14(296):1-12.
Rocha JP, Silva AEBC, Bezerra ALQ, Sousa MRG, Moreira IA. Eventos adversos identificados nos relatórios de enfermagem em uma clínica pediátrica. Ciencia Y Enfermeria. 2014;20(2):53-63.
Paiva MCMS, Popim RC, Melleiro MM, Tronchim DMR, Lima SAM, Juliani CMCM. The reasons of the nursing staff to notify adverse events. Rev Latino-Am Enfermagem. 2014;22(5):747-54.
Jahromi ZB, Parandavar N, Rahmanian S. Investigating Factors Associated with not Reporting Medical Errors From the Medical Team’S Point of View in Jahrom, Iran. Global Journal of Health Science. 2014;6(6):96-104.
Mendes W, Pavão ALB, Martins M, Moura MLO, Travassos C. The feature of preventable adverse events in hospitals in the State of Rio de Janeiro, Brazil. Rev Assoc Med Bras. 2013;59(5):421-8.
Paranaguá TTB, Bezerra ALQ, Camargo e Silva AEB, Azevedo Filho FM. Prevalence of no harm incidents and adverse events in a surgical clinic. Acta Paul Enferm. 2013;26(3):256-62.
Pancieri AP, Santos BP, Avila MAG, Braga EM. Safe surgery checklist: analysis of the safety and communication of teams from a teaching hospital. Rev Gaúcha Enferm. 2013;34(1):71-78.
Leitão IMTA, Oliveira RM, Leite SS, Sobral MC, Figueiredo SV, Cadete MC. Análise da comunicação de eventos adversos na perspectiva de enfermeiros assistenciais. Rev Rene. 2013;14(6):1073-83.
Pires MPO, Pedreira MLG, Peterlini MAS. Safe pediatric surgery: development and validation of preoperative interventions checklist. Rev Latino-Am Enfermagem. 2013;21(5):1080-7.
Lima RPM, Melleiro MM. Percepção da equipe multidisciplinar acerca de fatores intervenientes na ocorrência de eventos adversos em um hospital universitário. Rev Min Enferm. 2013;17(2):312-21.
Bohomol E, Tartali JA. Adverse effects in surgical patients: knowledge of the nursing professionals. Acta Paul Enferm. 2013;26(4):376-81.
Dias MAE, Martins M, Navarro N. Adverse outcome screening in hospitalizations of the Brazilian Unifi ed Health System. Rev Saúde Pública. 2012;46(4):719-29.
Fassini P, Hahn GV. Riscos à segurança do paciente em unidade de internação hospitalar: concepções da equipe de enfermagem. Rev Enferm UFSM. 2012;2(2):290-9.
Ramírez OJG, Gámez AS, Gutiérrez AA, Salamanca JG, Vega AG, Galeano EM. Una mirada actual de la cultura de seguridad del paciente. Av Enferm. 2011;29(2):363-374.
Ospina AMO, Velásquez MAV, Rivas DC. Caracterización de eventos adversos en una ESE de primer nivel en Caldas 2007 - 2009. Hacia la Promoción de la Salud. 2011;16(1):87-98.
Pavão ALB, Andrade D, Mendes W, Martins M, Travassos C. Estudo de incidência de eventos adversos hospitalares, Rio de Janeiro, Brasil: avaliação da qualidade do prontuário do paciente. Rev Bras Epidemiol. 2011;14(4):651-61.
Roque KE, Melo ECP. Adaptação dos critérios de avaliação de eventos adversos a medicamentos para uso em um hospital público no Estado do Rio de Janeiro. Rev Bras Epidemiol. 2010;13(4):607-19.
Françolin L, Gabriel CS, Melo MRAC, Correa JS. Eventos adversos e ferramentas para melhoria da segurança assistencial de enfermagem. Cuidarte Enfermagem. 2010;4(2):74-9.
Gimenes FRE, Mota MLS, Teixeira TCA, Silva AEBC, Opitz SP, Cassiani SHB. Patient safety in drug therapy and the influence of the prescription in dose errors. Rev Latino-Am Enfermagem. 2010;18(6):1055-61.
Bezerra ALQ, Silva AEBC, Branquinho NCSS, Paranaguá TTB. Análise de queixas técnicas e eventos adversos notificados em um hospital sentinela. Rev Enferm UERJ. 2009;17(4):467-72.
Balbino CM, Caramez LFC, Barbosa MS, Cavalcanti PCS, Silvino ZR, Teixeira ER, et al. Erros de medicação e a segurança do paciente: revisão sistematizada da literatura. Online Braz J Nurs. [Internet]. 2009 [acesso 20 mar 2015];8(3). Disponível em: http://www.objnursing.uff.br/index.php/nursing/article/view/j.1676-4285.2009.2599/569
Beccaria LM, Pereira RAM, Contrin LM, Lobo SMA, Trajano DHL. Nursing care adverse events at an intensive care unit. Rev Bras Ter Intensiva. 2009;21(3):276-82.
Nascimento CCP, Toffoletto MC, Gonçalves LA, Freitas WG, Padilha KG. Indicators of healthcare results: analysis of adverse events during hospital stays. Rev. Latino-Am. Enfermagem. 2008;16(4):746-51.
Bohomol E, Ramos LH. Erro de medicação: importância da notificação no gerenciamento da segurança do paciente. Rev Bras Enferm. 2007;60(16):32-6.
The works published in this magazine are subject to the following terms:
1. The Publications Service of the University of Murcia (the publisher) preserves the copyright of the published works, and encourages and allows the reuse of the works under the license for use stated in point 2.
© Servicio de Publicaciones, Universidad de Murcia, 2011 (© Publications Service, University of Murcia, 2011)
2. The works are published in the electronic edition of the journal under Creative Commons Reconocimiento-NoComercial-SinObraDerivada 3.0 España(texto legal) “ a Attribution-NonCommercial-NoDerivatives 3.0 Spain license (legal text)”. They can be copied, used, broadcasted, transmitted and publicly displayed, provided that: i) the authorship and original source of their publication (journal, publisher and URL) are cited; (ii) are not used for commercial purposes; iii) the existence and specifications of this license is mentioned.
3. Conditions of self-archiving. Authors are allowed and encouraged to electronically disseminate the pre-print (pre-reviewed ) and / or post-print (reviewed and accepted for publication) versions of their works prior to publication, as it ensures a wider circulation and dissemination which may lead to a possible increase in its mention and a higher scope among the academic community. RoMEO color: green.