Adverse events associated to the use of equipment and materials in nursing care of hospitalized patients.

Autor:	Xelegati R; Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada,Ribeirão Preto, São Paulo, Brasil., Gabriel CS; Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada,Ribeirão Preto, São Paulo, Brasil., Dessotte CAM; Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada,Ribeirão Preto, São Paulo, Brasil., Zen YP; Hospital Ribeirânia, Grupo São Lucas, Departamento de Qualidade, Ribeirão Preto, São Paulo, Brasil., Évora YDM; Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada,Ribeirão Preto, São Paulo, Brasil.
Jazyk:	Portuguese; English
Zdroj:	Revista da Escola de Enfermagem da U S P [Rev Esc Enferm USP] 2019 Aug 29; Vol. 53, pp. e03503. Date of Electronic Publication: 2019 Aug 29.
DOI:	10.1590/S1980-220X2018015303503
Abstrakt:	Objective: To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care. Method: Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital. Results: A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube - removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter - agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury - agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation - weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%). Conclusion: The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.
Databáze:	MEDLINE
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