Nivel de cumplimiento de metas internacionales de seguridad en un Sanatorio privado 2023 / Level of compliance with international safety goals in a private Sanatorium 2023

La presente investigación pretende evaluar el nivel de cumplimiento de las metas internacionales, que representan el foco principal para la mejora de calidad y seguridad de atención de los pacientes. La seguridad del paciente involucra a todos los estudios, prácticas y acciones promovidas por las instituciones sanitarias para disminuir y eliminar los riesgos de daños innecesarios relacionados con el cuidado de la salud. Metodología: Estudio descriptivo, observacional y transversal. De fuentes primaria y secundaria, Resultados: se abordaron las metas N° 1 la cual consiste en Identificar a los pacientes correctamente y la meta N° 6 la cual se refiere a Reducir el riesgo de lesiones en pacientes como resultado de caídas. En primer lugar, se destaca el cumplimiento en la identificación correcta del paciente y en segunda instancia la mejora del cumplimiento de medidas de prevención de caídas. Conclusión: Esta proximidad de los valores obtenidos genera un aspecto positivo para mejorar la seguridad de los pacientes y que, si bien el cumplimiento de las metas no es el deseado, es cercano al porcentaje planteado. Lo que en definitiva hace a este estudio un antecedente importante en la mejora continua con vista al futuro cercano[AU]

This research aims to evaluate the level of compliance with international goals, which represent the main focus for improving the quality and safety of patient care. Patient safety involves all studies, practices and actions promoted by health institutions to reduce and eliminate the risks of unnecessary harm related to health care. Methodology: Descriptive, observational and transversal study. From primary and secondary sources, Results: goals No. 1 were addressed, which consists of Identifying patients correctly and goal No. 6, which refers to Reducing the risk of injuries in patients as a result of falls. Firstly, compliance with correct patient identification stands out and secondly, improvement in compliance with fall prevention measures. Conclusion: This proximity of the values obtained generates a positive aspect to improve patient safety and that, although the fulfillment of the goals is not as desired, it is close to the proposed percentage. Which ultimately makes this study an important precedent in continuous improvement for the near future[AU]

Esta pesquisa tem como objetivo avaliar o nível de cumprimento das metas internacionais, que representam o foco principal para a melhoria da qualidade e segurança do atendimento ao paciente. A segurança do paciente envolve todos os estudos, e ações promovidas pelas instituições de saúde para reduzir e eliminar os riscos de danos desnecessários relacionados à assistência à saúde. Metodologia: Estudo descritivo, observacional e transversal. De fontes primárias e secundárias, dependendo do indicador e do objetivo para o qual a medição está sendo realizada. Resultados: Nesta pesquisa serão abordadas as metas nº1, que consiste em Identificar corretamente os pacientes e a meta nº 6, que es Reduzir o risco de lesões nos pacientes em decorrência de quedas. Foi realizado nos dois locais. Em primeiro lugar, destaca-se o cumprimento da correta identificação do paciente e, em segundo lugar, a melhoria no cumprimento das medidas de prevenção de quedas. Conclusão: Essa proximidade dos valores obtidos gera um aspecto positivo para melhorar a segurança do paciente e que, embora o cumprimento das metas não seja o desejado, está próximo do percentual proposto. O que acaba por tornar este estudo um precedente importante na melhoria contínua com vista ao futuro próximo.

Interrupções e distrações durante a preparação e administração de medicamentos de alto risco: Estudo transversal / Interruptions and distractions during the preparation and administration of high-risk medications: A cross-sectional study / Distracciones e interrupciones durante la preparación y administración de medicamentos de alto riesgo: Estudio transversal

Resumo Enquadramento: Estudos indicam que as interrupções contribuem para erros clínicos e falhas em procedimentos. Objetivo: Analisar as interrupções vivenciadas pelos enfermeiros durante a preparação e administração de medicamentos de alto risco. Metodologia: Foi realizado um estudo transversal numa unidade de cuidados intensivos e numa unidade de internamento. As interrupções vivenciadas pelos enfermeiros durante o processo de medicação foram observadas com a ajuda de duas checklists. A amostra foi selecionada por conveniência em abril e maio de 2019. Os dados quantitativos foram analisados através de estatística descritiva no programa IBM SPSS Statistics, versão 24.0, enquanto os dados qualitativos foram tratados por meio da análise de conteúdo. Resultados: Observaram-se 137 interrupções em 193 processos de medicação. A maioria das interrupções foi iniciada por outros membros da equipa de cuidados de saúde por meio de conversas. Estas interrupções foram maioritariamente prejudiciais e ocorreram durante a fase de preparação. A estratégia multitarefa foi utilizada para as gerir. Conclusão: As interrupções ocorridas durante o processo de medicação eram maioritariamente associadas com comunicações profissionais e sociais. A sua relevância diferiu consoante a fase do processo.

Abstract Background: Interruptions have been reported to contribute to clinical errors and procedural failures. Objective: To analyze the interruptions experienced by nurses during the preparation and administration of high-risk medications. Methodology: A cross-sectional study was conducted in an intensive care and inpatient unit. The interruptions experienced by nurses during the medication process were observed through two checklists. The sample was selected by convenience in April-May 2019. Descriptive statistics was used to analyze quantitative data in IBM SPSS Statistics software, version 24.0, while content analysis was used to analyze qualitative data. Results: In 193 medication processes, there were 137 interruptions. Other members of the healthcare team initiated most interruptions through conversations. These interruptions were mostly negative and occurred during the preparation phase. The multitasking strategy was used to manage them. Conclusion: Interruptions during the medication process were primarily associated with professional and social communications. The impact of these interruptions varied depending on the phase of the process.

Resumen Marco contextual: Se ha reportado la participación de distracciones en errores clínicos y fallos de procedimiento. Objetivo: Analizar las distracciones del personal de enfermería durante la preparación y administración de fármacos de alto riesgo. Metodología: Estudio transversal desarrollado en una unidad de cuidados intensivos y una unidad de hospitalización. Se observaron distracciones del personal de enfermería durante el proceso de medicación a través de dos listas de control. La muestra fue seleccionada por conveniencia (abril-mayo 2019). Los datos cuantitativos se analizaron mediante estadística descriptiva (IBM SPSS Statistics, versión 24.0). Los datos cualitativos se analizaron mediante análisis de contenido. Resultados: Hubo 137 distracciones en 193 procesos de medicación. La mayoría de las distracciones fueron iniciadas por otros miembros del equipo sanitario a través de conversaciones. La mayoría se produjeron en la fase de preparación y fueron negativas y se gestionaron mediante la estrategia multitarea. Conclusión: Las distracciones durante el proceso de medicación se referían principalmente a las comunicaciones profesionales y sociales. La importancia de esas distracciones variaba en función de la fase del proceso.

Incidência de obstrução em cateteres periféricos intravenosos em adultos e fatores relacionados / Incidence of obstruction in peripheral intravenous catheters in adults and related factors / Incidencia de obstrucción en catéteres intravenosos periféricos en adultos y factores relacionados

Objetivo: analisar a incidência e os fatores relacionados à obstrução de cateter intravenoso periférico em adultos hospitalizados. Método: uma coorte prospectiva, realizada a partir da observação de 203 cateteres, entre fevereiro de 2019 e maio de 2020, em hospital público e de ensino brasileiro. Foram consideradas variáveis clínicas e do cateter. Os dados foram analisados descritivamente e por estatística inferencial. Resultados: o tempo de permanência variou entre um a 15 dias e a obstrução ocorreu em 7,5% das observações. Houve aumento do risco de obstrução em relação ao sexo (RR=0,49 / p=0,186), à idade (RR=1,20/ p=0,732), aos cateteres de maior calibre (RR=0,53/ p=0,250), à inserção no dorso da mão até antebraço (RR=2,33/ p=0,114) e ao tempo do cateter in situ (RR=033/ p=0,433). Conclusão: O cuidado diário e observação do cateter intravenoso periférico são importantes para minimizar o surgimento de complicações locais e sistêmicas e manter a patência do dispositivo.

Objective: to analyze the incidence and factors related to peripheral intravenous catheter obstruction in hospitalized adults. Method: a prospective cohort, based on the observation of 203 catheters, between February 2019 and May 2020, in a Brazilian public teaching hospital. Clinical and catheter variables were taken into account. The data was analyzed descriptively and using inferential statistics. Results: the length of stay ranged from one to 15 days and obstruction occurred in 7.5% of the observations. There was an increased obstruction risk in relation to gender (RR=0.49 / p=0.186), age (RR=1.20/ p=0.732), larger catheters (RR=0.53/ p=0.250), insertion in the back of the hand up to the forearm (RR=2.33/ p=0.114) and the time length the catheter was in situ (RR=033/ p=0.433). Conclusion: Daily care and observation of the peripheral intravenous catheter is important to minimize the appearance of local and systemic complications and maintain the patency of the device.

Objetivo: analizar la incidencia y los factores relacionados con la obstrucción del catéter intravenoso periférico en adultos hospitalizados. Método: cohorte prospectiva, realizada mediante la observación de 203 catéteres, entre febrero de 2019 y mayo de 2020, en un hospital escuela público brasileño. Se consideraron variables clínicas y del catéter. Los datos se analizaron de forma descriptiva y mediante estadística inferencial. Resultados: el tiempo de permanencia varió entre uno y 15 días y la obstrucción ocurrió en el 7,5% de las observaciones. Hubo mayor riesgo de obstrucción en relación con el sexo (RR=0,49 / p=0,186), la edad (RR=1,20 / p=0,732), los catéteres de mayor calibre (RR=0,53 / p= 0,250), la inserción en el dorso de la mano hasta el antebrazo (RR=2,33/ p=0,114) y el tiempo del catéter in situ (RR=033/ p=0,433). Conclusión: el cuidado diario y la observación del catéter intravenoso periférico son importantes para minimizar la aparición de complicaciones locales y sistémicas y mantener la permeabilidad del dispositivo.

[Translated article] Medication reconciliation in hospitalized haematological patients.

OBJECTIVE: The main objective is to analyse unjustified discrepancies found during the medication reconciliation process in patients admitted to the Haematology Service of our hospital, in addition to the pharmaceutical interventions carried out. As a secondary objective, to detect possible points of the procedure to be perfected with a view to protocolizing the medication reconciliation process in haematological patients that adapts to the conditions of our center. METHODS: Cross-sectional observational pilot study carried out in a reference hospital in haematology for a population of 800 000 inhabitants. Adult inpatients admitted to the Haematology Service between August and October 2022 whose medication had been reconciled were included. The main variables were: number and type of unjustified discrepancy, proposed pharmaceutical intervention, and degree of acceptance. RESULTS: 36 conciliation processes were analysed, 34 admissions and 2 intrahospital transfer. 58.3% of the patients presented some unjustified discrepancy. 38 unjustified discrepancies were detected, with an acceptance of pharmaceutical interventions of 97.4%. The most common types of discrepancy were medication omission (56.8%) and drug interaction (24.3%). The most frequent pharmaceutical interventions were reintroducing medication (48.6%) and suspending treatment (16.2%). Polypharmacy and receiving chemotherapy treatment multiply by 4 the probability of presenting drug interactions. CONCLUSIONS: The most common unjustified discrepancies in the medication reconciliation process in hospitalized haematology patients are: medication omission and drug interactions. The reintroduction of medication and suspension of the prescription are the most frequent accepted pharmaceutical interventions. Polypharmacy is related to an increase in unjustified discrepancies. The factors that promote the appearance of interactions are admissions to receive chemotherapy treatment and polypharmacy. The main point of improvement detected is the need to create a circuit that allows conciliation to be carried out on discharge. Medication reconciliation contribute to improving patient safety by reducing medication errors.

Patient safety in the intensive care department.

Patient safety is a priority for all healthcare systems. Despite this, too many patients still suffer harm as a consequence of healthcare. Furthermore, it has a significant impact on family members, professionals and healthcare institutions, resulting in considerable economic costs. The critically ill patient is particularly vulnerable to adverse events. Numerous safe practices have been implemented, acknowledging the influence of human factors on safety and the significance of the well-being of professionals, as well as the impact of critical episodes at hospital discharge on patients and their families. Training and engagement of professionals, patients and families are of paramount importance. Recently, artificial intelligence has demonstrated its ability to enhance clinical safety. This update on "Patient Safety" reviews all these aspects related to one of the most pivotal dimensions of healthcare quality.

Analysis of medication errors in Neonatal Intensive Care: A systematic review.

Medication errors, potentially causing harm and causing harm, increase significantly in newborns cared for in intensive care settings. In this sense, this work carries out a systematic review to analyze the most current evidence in relation to medication errors in neonatal intensive care, discussing the topics that refer to health technology from smart pumps, cost-effectiveness of medications, the practice of nursing professionals on the medication administration process and quality improvement models. In this way, it could be considered a useful tool to promote quality and safety in neonatal intensive care.

Segurança do paciente em serviços de saúde mental extra-hospitalares: uma revisão integrativa / Patient safety in out-of-hospital mental health services: an integrative review / Seguridad del paciente en los servicios de salud mental extrahospitalarios: una revisión integradora

Este artigo visa analisar a produção científica publicada na literatura sobre segurança do paciente em serviços de saúde mental extra-hospitalares por meio de uma revisão integrativa da literatura. Esse levantamento bibliográfico ocorreu em janeiro de 2023 por meio das bases de dados Índice Bibliográfico Español en Ciencias de la Salud (Ibecs), Base de Dados de Enfermagem (BDENF), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline), National Library of Medicine (PubMed) e Web of Science. A amostra final resultou em nove artigos categorizados em três eixos temáticos, conforme o tipo de assunto que foi abordado. Como conclusão, esta revisão integrativa da literatura ressaltou a importância da segurança do paciente nos serviços de saúde mental no contexto extra-hospitalar e destacou a necessidade de uma maior atenção e investimento nessa área: também foi possível identificar lacunas e contribuir para o avanço do conhecimento nesse campo da saúde mental.

This study analyzes the scientific literature on patient safety in out-of-hospital mental health services. An integrative literature review was conducted. Bibliographic survey was performed in January 2023 on the Spanish Bibliographic Index in Health Sciences (Ibecs), Nursing Database (BDENF), Latin American and Caribbean Health Sciences Literature (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline), National Library of Medicine (PubMed) and Web of Science databases. The final sample included nine articles categorized into three thematic axes according to the subject addressed. Results highlighted the importance of patient safety in out-of-hospital mental health services and the need for greater attention and investment in this area. It identified gaps, contributing to further advance knowledge in this field.

Este estudio tuvo por objetivo analizar la producción científica sobre la seguridad del paciente en los servicios extrahospitalarios de salud mental a partir de una revisión integradora de la literatura. Se realizó una búsqueda en enero de 2023 en las bases de datos Índice Bibliográfico Español en Ciencias de la Salud (Ibecs), Base de Datos de Enfermería (BDENF), Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs), Medical Literature Analysis and Retrieval System Online (Medline), Biblioteca Nacional de Medicina (PubMed) y Web of Science. La muestra final estuvo compuesta por nueve artículos categorizados en tres ejes temáticos, según el tipo de tema abordado. Esta revisión integradora de la literatura destacó la importancia de la seguridad del paciente en los servicios de salud mental en el contexto extrahospitalario y destacó la necesidad de una mayor atención e inversión en esta área; además, fue posible identificar brechas y contribuir al avance del conocimiento en este campo de la salud mental.

Falls in older adults hospitalized in tertiary centers in Colombia. Clinical description and complications.

OBJECTIVE: The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community. The aim was to determine the characteristics of patients who suffered in-hospital falls and their complications. METHODS: This was a cross-sectional study with patients older than 64 years of age, admitted between 2018 and 2020 to four clinics in Colombia who presented a fall during their stay. Clinical data, reasons for the fall, complications and use of drugs with a known risk for causing falls and with an anticholinergic load were reviewed. RESULTS: A total of 249 patients were included. The mean age was 77.5 ± 7.4 years, and there was a predominance of males (63.9%). The patients were hospitalized mainly for community-acquired pneumonia (12.4%) and heart failure (10.4%). Falls occurred most frequently in hospitalization wards (77.1%) and emergency departments (20.9%). Falls were related to standing alone (34.4%) and on the way to the bathroom (28.9%), with 40.6% (n = 102) of falls resulting in trauma, especially to the head (27.7%); the incidence of fractures was low (3.2%). Ninety-two percent of patients had polypharmacy (≥5 drugs), 88.0% received psychotropic drugs, and 37.3% received drugs with an anticholinergic load ≥3 points. CONCLUSIONS: Hospitalized adults over 65 years of age suffered falls, mainly in hospitalization wards and emergency departments, especially during the process of solitary ambulation. Most had received psychotropic drugs and medications with a high anticholinergic load. These results suggest that it is necessary to improve risk prevention strategies for falls in this population.

Instruments and Warning Signs for Identifying and Evaluating the Frequency of Adverse Events in Intermediate and Long-Term Care Centres: A Narrative Systematic Review.

INTRODUCTION: There is a lack of data about adverse events (AE) in intermediate and long-term care centers (ILCC). We aimed to synthesize the available scientific evidence on instruments used to identify and characterize AEs. We also aimed to describe the most common adverse events in ILCCs. MATERIAL AND METHODS: A narrative systematic review of the literature was conducted according to Prisma recommendations. The PubMed database was searched for articles published between 2000 and 2021. Two reviewers independently screened and reviewed the studies through blind and independent review. We evaluated bias risk with Cochrane's risk of bias tool. Disagreements were resolved by consensus. Discrepancies that were not resolved by discussion were discussed with a third reviewer. Descriptive data was extracted and qualitative content analysis was performed. RESULTS: We found 2191 articles. Based on the inclusion and exclusion criteria, 272 papers were screened by title and abstract, and 66 studies were selected for full review. The instruments used to identify AEs were mostly tools to identify specific AEs or risks of AEs (94%), the remaining 6% were multidimensional. The most frequent categories detected medication-related AEs (n=26, 40%); falls (n=7, 11%); psychiatric AEs (6.9%); malnutrition (4.6%), and infections (4.6%). The studies that used multidimensional tools refer to frailty, dependency, or lack of energy as predictors of AEs. However, they do not take into account the importance of detecting AEs. We found 2-11 adverse drug events (ADE) per resident/month. We found a prevalence of falls (12.5%), delirium (9.6-89%), pain (68%), malnutrition (2-83%), and pressure ulcers (3-30%). Urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis were the most common infections in this setting. Transitions between different care settings (from hospitals to ILCC and vice versa) expose AE risk. CONCLUSION: There are many instruments to detect AEs in ILCC, and most have a specific approach. Adverse events affect a significant proportion of patients in ILCC, the nurse-sensitive outcomes, nosocomial infections, and adverse drug events are among the most common. The systematic review was registered with Prospero, ID: CRD42022348168.

Risk management of radioiodine treatment in differentiated thyroid cancer.

INTRODUCTION: Patient safety is paramount in providing quality healthcare and constitutes a global concern for healthcare systems. Radioiodine treatment to patients with well-differentiated thyroid cancer is not without risks. The aim of this study is to identify, evaluate and mitigate the risks associated with this procedure. MATERIALS AND METHODS: A single-centre descriptive study was conducted in which risk management was carried out by establishing a risk map using FMEA methodology. RESULTS: Based on the process map 6 sub-processes and 23 failure modes in the three phases of the treatment process were analysed. According to risk priority number (RPN), the sub-process with the highest risk was administrative management (RPN 82), followed by treatment per se and post-treatment imaging (both with RPN 70). An overall process RPN of 300 (156 pre-treatment, 74 treatment and 70 post-treatment) was obtained. Failures directly related to the patient pose a high risk. The implementation of verification systems, performing tasks earlier and providing quality medical information are the most relevant preventive measures to be implemented. CONCLUSIONS: The application of the FMEA methodology in the risk management for radioiodine treatment is a valuable tool for improving the quality and safety of this process. The risk map has been able to identify failures at different stages, assess their causes and effects, prioritise the risks identified and implement preventive and corrective measures that can be monitored, ensuring the effectiveness of the actions taken.

Adverse events with arterial catheters in intensive care units: a scoping review.

INTRODUCTION: The installation of an arterial line is one of the invasive procedures performed for hemodynamic monitoring and, even with its clear importance in intensive care, it is still an invasive procedure and liable to cause harms to the patients. OBJECTIVE: To identify the adverse events associated with the use of arterial catheters in critically-ill patients in the world scientific production. METHODOLOGY: The present scoping review was conducted according to the JBI methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used for reporting. The research question was "Which adverse events related to the use of arterial catheters in patients admitted to intensive care are more evident in the literature?". Data collection took place in the following databases: LILACS; MEDLINE; EMBASE; CINAHL, EBSCOhost; and WEB OF SCIENCE. RESULTS: Through the search strategies, 491 articles were found in the databases. After exclusion of duplicates, peer analysis of titles and abstracts, full reading and screening of lists of references, the final sample of studies included was 38 articles. The main harms cited by the publications were as follows: limb ischemia, thrombosis, hemorrhage, accidental removal, inadvertent connection of inadequate infusion solution, pseudoaneurysm and bloodstream infection. CONCLUSIONS: It was evidenced that patients are subjected to risks of adverse events from the insertion moment to removal of the arterial catheter, focusing on the infusion solution used to fill the circuit, the type of securement and dressings chosen, as well as the Nursing care measures for the prevention of bloodstream infection.

Proposal for a complementary safety checklist for spine surgery.

INTRODUCTION: Once the World Health Oraganization (WHO) generic surgical checklist has been standardized and following the itinerary proposed, it is up to the different specialties to continue advancing in the improvement and adjustment of the checklists to their specific procedures. METHODS: Through a Failure Mode and Effects Analysis (FMEA) in which professionals from the surgical area of ​​the Torrecárdenas University Hospital, Jaén Hospital Complex and Gregorio Marañón General University Hospital participated, aspects that threaten patient safety in spine surgery and that are not included in the WHO generic surgical checklist were proposed. The authors scored each of the proposed items incrementally based on the degree of suitability. Based on the score obtained, they selected those who would be incorporated into the specific safety checklist. RESULTS: A total of twenty-one candidate items were proposed to be part of the specific check list. These obtained scores between 15 and 11 points. After scoring them, it was decided to include the thirteen best rated in the definitive surgical checklist, seven of them in the initial phase, two in the phase prior to the incision and another four in the final part of the checklist prior to the completion of the procedure. CONCLUSIONS: Professionals in the surgical area of ​​Neurosurgery can identify aspects not included in the generic checklist whose non-compliance can affect patient safety in spine surgery to at least the same extent as those included in WHO checklist. It is possible to propose a specific complementary checklist for spinal surgery, responsible for collecting aspects related to safety and success in these procedures.

Cultura de segurança em unidades de terapia intensiva na perspectiva da equipe multiprofissional: Estudo multicêntrico / Cultura de seguridad en unidades de terapia intensiva en la perspectiva del equipo multiprofesional: Estudio multicéntrico / Safety Culture in intensive care units from multiprofessional team perspective: A multicenter study

Resumo Introdução: A Cultura de Segurança do Paciente é considerada um importante componente estrutural dos serviços, que favorece a implantação de práticas seguras e a diminuição da ocorrência de eventos adversos. Objetivo: Identificar os fatores associados à cultura de segurança do paciente nas unidades de terapia intensiva adulto em hospitais de grande porte da região Sudeste do Brasil. Método: Estudo transversal do tipo survey e multicêntrico. Participaram 168 profissionais de saúde de quatro unidades (A, B, C e D) de terapia intensiva adulto. Foi utilizado o questionário "Hospital Survey on Patient Safety Culture". Considerou-se como variável dependente o nível de cultura de segurança do paciente e variáveis independentes aspectos sociodemográficos e laborais. Foram usadas estatísticas descritivas e para a análise dos fatores associados foi elaborado um modelo de regressão logística múltipla. Resultados: Identificou-se associação entre tipo de hospital com onze dimensões da cultura de segurança, quanto à função a categoria profissional médico, técnico de enfermagem e enfermeiro foram relacionadas com três dimensões; o gênero com duas dimensões e tempo de atuação no setor com uma dimensão. Conclusão: Evidenciou-se que o tipo de hospital, categoria profissional, tempo de atuação no setor e gênero foram associados às dimensões de cultura de segurança do paciente.

Resumen Introducción: La cultura de seguridad del paciente se considera un componente estructural importante de los servicios, que favorece la aplicación de prácticas seguras y la reducción de la aparición de acontecimientos adversos. Objetivo: Identificar los factores asociados a la cultura de seguridad del paciente en unidades de terapia intensiva adulto en hospitales de la región Sudeste del Brasil. Metodología: Estudio transversal de tipo encuesta y multicéntrico. Participaron 168 profesionales de salud de cuatro unidades (A, B, C y D) de terapia intensiva adulto. Se utilizó el cuestionario "Hospital Survey on Patient Safety Culture". Se consideró como variable dependiente el nivel de cultura de seguridad del paciente y variables independientes los aspectos sociodemográficos y laborales. Fueron usadas estadísticas descriptivas y, para analizar los factores asociados, fue elaborado un modelo de regresión logística múltiple. Resultados: Se identificó asociación entre tipo de hospital con once dimensiones de cultura de seguridad del paciente. En relación a la función, personal médico, técnicos de enfermería y personal de enfermería fueron asociados con tres dimensiones, el género con dos dimensiones y tiempo de actuación con una dimensión en el modelo de regresión. Conclusión: Se evidenció que el tipo de hospital, función, tiempo de actuación en el sector y género fueron asociados a las dimensiones de la cultura de seguridad del paciente.

Abstract Introduction: Patient safety culture is considered an important structural component of the services, which promotes the implementation of safe practices and the reduction of adverse events. Objective: To identify the factors associated with patient safety culture in adult intensive care units in large hospitals in Belo Horizonte. Method: Cross-sectional survey and multicenter study. A total of 168 health professionals from four units (A, B, C and D) of adult intensive care participated. The questionnaire "Hospital Survey on Patient Safety Culture" was used. The patient's level of safety culture was considered as a dependent variable, and sociodemographic and labor aspects were the independent variables. Descriptive statistics were used and a multiple logistic regression model was developed to analyze the associated factors. Results: An association was identified between the type of hospital and eleven dimensions of the safety culture. In terms of function, the doctors, nursing technicians, and nurse were related to three dimensions; gender with two dimensions, and time working in the sector with one dimension. Conclusion: It was evidenced that the type of hospital, function, time working in the sector, and gender were associated with the dimensions of patient safety culture.

Eventos adversos e queixas técnicas de tecnologias para o manejo de estomias de eliminação no Brasil / Adverse Events and Technical Complaints of Technologies for the Management of Elimination Ostomies in Brazil / Eventos adversos y quejas técnicas de tecnologías para el manejo de ostomías de eliminación en Brasil

Objetivo: Describir los eventos adversos y las quejas técnicas relacionadas con tecnologías para el manejo de ostomías de eliminación reportadas en Brasil. Método: Estudio descriptivo y transversal realizado con datos secundarios registrados en Notivisa. Los datos representan eventos adversos y quejas técnicas reportadas desde enero de 2007 hasta agosto de 2023. Se utilizaron recursos de estadística descriptiva para el análisis. Resultados: Se identificaron un total de 2.812 notificaciones, de las cuales 101 (3,6%) fueron eventos adversos y 2.711 (96,4%) quejas técnicas. El estado de São Paulo representó 884 (31,4%) de las notificaciones. Las bolsas recolectoras fueron los productos más reportados, con 2.688 (95,6%) notificaciones, incluyendo 84 (3,1%) eventos adversos y 2.604 (96,9%) quejas técnicas. En cuanto a los resultados, hubo falta de información en 2.718 (96,7%) de las notificaciones, retención urinaria en 19 (0,67%), dermatitis en 13 (0,46%) y lesiones cutáneas en 9 (0,32%). Conclusión: El número de notificaciones ha seguido aumentando en los últimos años, pero la calidad sigue siendo baja, representada por un alto índice de información omitida. Las quejas técnicas sobre las bolsas recolectoras representan el mayor número de notificaciones en Brasil. La descripción de los resultados en el uso de productos para el tratamiento de las ostomías no es clara y puede llevar a un subregistro de eventos adversos importantes, como la dermatitis. (AU)

Objetivo: Descrever os eventos adversos e as queixas técnicas de tecnologias para o manejo de estomias de eliminação notificados no Brasil. Método: Estudo transversal, descritivo, realizado por meio de dados secundários registrados no Notivisa. Os dados representam eventos adversos e queixas técnicas notificados no período de janeiro de 2007 a agosto de 2023. Para análise, utilizaram-se recursos da estatística descritiva. Resultados: Identificaram-se 2.812 notificações, das quais 101 (3,6%) eram eventos adversos e 2.711 (96,4%) queixas técnicas. O estado de São Paulo foi responsável por 884 (31,4%) notificações. As bolsas coletoras foram os produtos mais notificados, apresentando 2.688 (95,6%) notificações, sendo 84 (3,1%) eventos adversos e 2.604 (96,9%) queixas técnicas. Sobre os desfechos, verificou-se a ausência de informações em 2.718 (96,7%) notificações, 19 (0,67%) notificações de retenção urinária, 13 (0,46%) de dermatite e 9 (0,32%) de lesão cutânea. Conclusão: O número de notificações permanece em ascendência nos últimos anos; entretanto, a qualidade ainda é baixa, representada por alta taxa de omissão de informações. As queixas técnicas de bolsas coletoras representam maior número de notificações no Brasil. A descrição dos desfechos na utilização de produtos para manejo de estomias não é clara e pode gerar subnotificação de eventos adversos importantes, como a dermatite. (AU)

Objective: To describe adverse events and technical complaints involving technologies for the management of elimination ostomies reported in Brazil. Method: This cross­sectional descriptive study used secondary data recorded in the Notivisa system. The data encompass adverse events and technical complaints reported from January 2007 to August 2023. Descriptive statistical tools were used for the analysis. Results: A total of 2,812 notifications were identified, of which 101 (3.6%) were adverse events, and 2,711 (96.4%) were technical complaints. The state of São Paulo accounted for 884 (31.4%) notifications. Collection bags were the most frequently reported products, with 2,688 (95.6%) notifications, including 84 (3.1%) adverse events and 2,604 (96.9%) technical complaints. Regarding outcomes, 2,718 (96.7%) notifications lacked information, 19 (0.67%) reported urinary retention, 13 (0.46%) reported dermatitis, and 9 (0.32%) reported skin injury. Conclusion: The number of notifications has continued to rise in recent years; however, the quality remains low, as evidenced by the high rate of omitted information. Technical complaints about collection bags represent the largest number of notifications in Brazil. The description of outcomes in the use of products for ostomy management is unclear and may lead to the underreporting of significant adverse events such as dermatitis. (AU)

Cómo generar recomendaciones de tromboprofilaxis venosa en instituciones de salud / How to generate recommendations for venous thromboprophylaxis in health institutions?

Resumen La prevención de la enfermedad tromboembólica venosa (ETV) es motivo de continua actualización en función de nueva evidencia que se genera permanentemente. Cada institución debe contar con una estrategia activa de prevención contra la ETV y debe generar normas de tromboprofilaxis (TP) de acuerdo con la realidad local. Durante este proceso de adaptación de una guía a la región debemos siempre tener en cuenta los recursos locales disponibles, el riesgo tromboembólico y hemorrágico propio del paciente, de la enfermedad por la que se encuentra internado (ya sea clínica o quirúrgica) y las consideraciones o preferencias del paciente. La tasa de adherencia a recomendaciones locales de TP es uno de los indicadores de excelencia más importantes evaluados en organismos que califican la calidad de una institución de salud. Las medidas de profilaxis que propongamos para los centros de salud, deben ser individualizadas para cada paciente, tienen que considerar antecedentes personales y familiares del enfermo y utilizar modelos de evaluación de riesgo validados de trombosis y de sangrado. También deben incluir a la población con riesgo de trombosis persistente luego del alta. Lo ideal es tener estadísticas propias de cada nosocomio para la toma de decisiones de cómo implementar una correcta TP. Extrapolar guías de los países desarrollados a nuestro ámbito podría tener un impacto negativo, si no se conoce la propia realidad. En este documento encontraremos herramientas prácticas para las instituciones de salud de la región, que les permita orientarse al momento de confeccionar recomendaciones para una adecuada TP.

Abstract Venous thromboembolism disease (VTE) prevention strategy has to be constantly updated based on new evidence that is generated every year. Each institution must have a formal and active prevention policy against VTE and must develop guidelines or standards for thromboprophylaxis (TP) according to the local reality. During this process of adapting a guideline to the region and the generation of hospital recommendations, we must always consider the available local resources, the thromboembolic and hemorrhagic risk of the patients, even after discharge, and also their considerations and preferences. Adherence to local TP recommendations is one of the most important items evaluated by organizations that measure institutional quality. Individualized prophylaxis should consider personal and family history of VTE, the use of validated risk assessment models or RAMs for thrombosis and bleeding events, as well as the special characteristics of each patient. Ideally, each center's own statistics should be available for decision-making. Extrapolating guidelines from developed countries could have a negative impact, if we ignore our hospital´s reality. In this document we will find practical tools for health institutions that will allow them to prepare recommendations or guidelines for adequate VTE prophylaxis.

Eventos adversos em crianças submetidas a cirurgias orofaciais / Adverse events in children submitted to orofacial surgery / Eventos adversos en niños sometidos a cirugía orofacial

Objetivo: Identificar os eventos adversos no pós-operatório imediato de queiloplastia e/ou palatoplastia em crianças e comparar os eventos identificados aos notificados ao Núcleo de Segurança do Paciente. Métodos: Estudo descritivo, retrospectivo e quantitativo, realizado em um hospital público e terciário brasileiro. Os dados foram coletados por meio da descrição nos registros de enfermagem e comparados aos notificados ao Núcleo de Segurança do Paciente, referente a junho e dezembro de 2019. Os resultados foram submetidos a análise estatística descritiva. Resultados: A amostra constou de 203 crianças, das quais 51% (n=103) apresentaram evento adverso. Foram identificados 176 eventos adversos, de 8 tipos, com prevalência da laringite pós-extubação (n=50; 28%), edema de língua (n=34; 19%) e lesão de comissura labial (n=25; 14%). Destes, apenas 5% (n=9) foram notificados ao Núcleo de Segurança do Paciente. Conclusão: Os eventos adversos prevalentes se relacionaram a cavidade oral e tecidos adjacentes, e a subnotificação foi expressiva. (AU)

Objective: To identify adverse events in the immediate postoperative period of cheiloplasty and/or palatoplasty in children and compare the identified events to those notified to the Patient Safety Center. Methods: Descriptive, retrospective and quantitative study, carried out in a Brazilian public and tertiary hospital. Data were collected through descriptions in nursing records and compared to those notified to the Patient Safety Center, referring to June and December 2019. The results were subjected to descriptive statistical analysis. Results: The sample consisted of 203 children, of which 51% (n=103) had an adverse event. A total of 176 adverse events of 8 types were identified, with prevalence of post-extubation laryngitis (n=50; 28%), tongue edema (n=34; 19%) and labral commissure lesion (n=25; 14%). Of these, only 5% (n=9) were notified to the Patient Safety Center. Conclusion: The prevalent adverse events were related to the oral cavity and adjacent tissues, and underreporting was significant. (AU)

Objetivo: Identificar eventos adversos en el postoperatorio inmediato de queiloplastia y/o palatoplastia en niños y comparar los eventos identificados con los notificados al Centro de Seguridad del Paciente. Métodos: Estudio descriptivo, retrospectivo y cuantitativo, realizado en un hospital público y terciario brasileño. Los datos se recolectaron mediante descripciones en registros de enfermería y se compararon con los notificados al Centro de Seguridad del Paciente, referidos a junio y diciembre de 2019. Los resultados fueron sometidos a análisis estadístico descriptivo. Resultados: La muestra estuvo conformada por 203 niños, de los cuales el 51% (n = 103) tuvo un evento adverso. Se identificaron un total de 176 eventos adversos de 8 tipos, con prevalencia de laringitis posextubación (n=50; 28%), edema de lengua (n=34; 19%) y lesión de la comisura del labrum (n=25; 14%). De estos, solo el 5% (n=9) fueron notificados al Centro de Seguridad del Paciente. Conclusion: Los eventos adversos prevalentes se relacionaron con la cavidad bucal y los tejidos adyacentes y el subregistro fue significativo. (AU)

Aplicabilidade das tecnologias na assistência de enfermagem com foco na segurança do paciente / The technology applicability in the aid of nursing focusing on the patient's safety / Aplicabilidad de tecnologias en la asistencia de enfermeria con enfoque en la seguridad del paciente

Objetivo: Conhecer a percepção dos enfermeiros em ambiente hospitalar sobre a implementação das tecnologias na assistência de enfermagem com foco na segurança do paciente. Métodos: Estudo descritivo, qualitativo, realizado com oito enfermeiros, responsáveis pelo gerenciamento de riscos em hospitais. Utilizou-se a técnica Snowball para eleger os participantes e a plataforma Skype para as entrevistas, realizadas no período de março a abril de 2021. Resultados: Apontou-se a utilização da tecnologia por meio do prontuário eletrônico, com a inserção de programa como o Tasy, o qual avançou para comunicação em rede, com vistas a facilitar checagens, auditorias, indicadores, gerenciamento e análise dos eventos. Desvelou-se também para a utilização do código de barras na identificação do paciente e no controle de dispensação e recebimento de medicamentos. No entanto, foram apresentadas limitações na implementação como dificuldade no manuseio das ferramentas digitais por profissionais antigos, caracterizada como resistência. Conclusão: A aplicabilidade das tecnologias na práxis da enfermagem contribui para a segurança do paciente face a favorecer o controle de eventos e o gerenciamento de riscos. Remete para a importância de capacitação e treinamentos dos profissionais para desenvolvimento de habilidades na utilização das ferramentas digitais. (AU)

Objective: Getting to know the perceptions from nurses on hospital environment about the technology implantation in the aid of patient's safety focused nursing. Methods: Descriptive, qualitative study made with eight nurses, responsible for risk management in hospitals. The Snowball technique was used to select the participants and the Skype platform used in the interviews, from March to April 2021. Results: The technology use was detected on the patient's electronic records through the Tasy program, which advanced to a net communication to facilitate checking, audits, pointers, management and event analysis. It was also detected by the use of bar codes in the identification of patients and control of medication dispensation and receiving. However, some limitations were found in the technology implementation, like elderly people having trouble using the digital tools, which is characterized by resistance. Conclusion: The technology applicability in the nursing practice contributes to the patient's safety to favor event control and risk management. It points to the importance of staff training and qualification to promote the ability of using digital tools. (AU)

Objetivo: Conocer las percepciones de las enfermeras del entorno hospitalario sobre la implementación de tecnologias enfocado en la seguridad del paciente. Métodos: Fue realizado un estudio descripctivo, cualitativo, con ocho enfermeras responsables de la gestión de riesgos en los hospitales. Se utilizó la tecnica snowball para elegir a los participantes y la plataforma skype para las entrevistas realizadas de marzo a abril de 2021. Resultados: Con el desarrollo de la tecnologia a través de historias clínicas eletrónicas, la inserción de un programa como Tasy, que avanzó a la comunicación em red, con el objetivo de facilitar verificaciones como auditorias, gestión y análisis en cualquier eventualidad. Tambien se dio a conocer para el uso de códigos de barras en la identificación de pacientes y en el control de la dispensación y recepción de medicamentos. Sin embargo, se presentaron limitaciones en la implementación, como la dificultad en el manejo de herramientas digitales por parte de algunos profesionales. Conclusión: La aplicabilidad de tecnologias en la enfermeria contribuye a la seguridad del paciente favoreciendo en el control de riesgos. Se refiere a la importancia de la calificación y formación de los profesionales, para desarrollar habilidades en el uso de herramientas digitales. (AU)

Gerenciamento do protocolo de prevenção de lesão por pressão: construção de painel de bordo informatizado / Management of the pressure injury prevention protocol: construction of a computerized dashboard / Gestión del protocolo de prevención de lesiones por presión: construcción de panel informatizado

Objetivo: Relatar a construção e implantação de painel de bordo, desenvolvido por enfermeiros e profissionais da tecnologia da informação, para gerenciamento do Protocolo de Prevenção de Lesão por Pressão. Métodos: Trata-se de um relato de experiência sobre a construção e implantação de painel de bordo informatizado para gerenciamento de protocolo em um hospital privado universitário, localizado no interior do estado de São Paulo. Resultados: A construção do painel de bordo foi dividida nas seguintes etapas: revisão e atualização do protocolo, construção do modelo eletrônico e implementação. A divulgação foi realizada pela Comissão de Prevenção de Lesão por Pressão. Conclusão: O painel de bordo possibilitou a visualização rápida e em tempo real dos riscos dos pacientes, intervenções propostas e efetividade das medidas de prevenção, além de promover a integração e empoderamento dos profissionais na gestão do cuidado. (AU)

Objective: To report the construction and implementation of a dashboard, developed by nurses and information technology professionals, to manage the Pressure Injury Prevention Protocol. Methods: This is an experience report on the construction and implementation of a computerized dashboard for protocol management in a private university hospital, located in the interior of the state of São Paulo. Results: The construction of the dashboard was divided into the following steps: review and update of the protocol, construction of the electronic model and implementation. The Pressure Injury Prevention Commission disclosed the tool. Conclusion: The dashboard enabled the quick and real-time visualization of patient risks, proposed interventions and effectiveness of prevention measures, in addition to promoting the integration and empowerment of professionals in the management of care. (AU)

Objetivo: Informar la construcción e implementación de un panel, desarrollado por enfermeras y profesionales de tecnologías de la información, para gestionar el Protocolo de Prevención de Lesiones por Presión. Métodos: Se trata de un informe de experiencia sobre la construcción e implementación de un panel computarizado para la gestión del protocolo en un hospital universitario privado, en el interior del estado de São Paulo. Resultados: La construcción del panel se dividió en los siguientes pasos: revisión y actualización del protocolo, construcción del modelo electrónico e implementación. La divulgación fue realizada por la Comisión de Prevención de Lesiones por Presión. Conclusión: El panel permitió la visualización rápida y en tiempo real de los riesgos del paciente, las intervenciones propuestas y la efectividad de las medidas de prevención, además de promover la integración y el empoderamiento de los profesionales en la gestión del cuidado. (AU)

Punto G: enfoque anatómico y seguridad del paciente / G-spot: anatomical approach and patient safety

Se investiga la región uretro-vaginal (pared posterior de la uretra ­ pared anterior de la vagina), en el área que corresponde a la descripción del "punto G", con el fin de colaborar a la discusión respecto de si existe una estructura morfológica que lo identifique. Se destaca una mayor y ocasional distribución venosa en esta zona, que puede explicar el fenómeno fisiológico descrito por Gräfenberg. Para los ginecólogos, urólogos y sexólogos, el conocimiento de la anatomía funcional de esa región tiene importancia para tratar las disfunciones orgásmicas además de la incontinencia urinaria. Esta situación controvertida influye en el marco actual de la seguridad del paciente

The urethro-vaginal region (posterior wall of the urethra ­ anterior wall of the vagina) is investigated, in the area that corresponds to the description of the "G-spot", in order to contribute to the discussion regarding whether there is a morphological structure that identifies it. A greater and occasional venous distribution in this area stands out, which may explain the physiological phenomenon described by Gräfenberg. For gynecologists, urologists and sexologists, knowledge of the functional anatomy of that region is important to treat orgasmic dysfunctions in addition to urinary incontinence. This controversial situation influences the current framework of patient safety

Álbum seriado acolher educando sobre classificação de risco / Serial album host educating on risk classification / Anfitrión de álbumes en serie que educa sobre la clasificación de riesgos

Objetivo: relatar a produção de uma tecnologia educacional sobre classificação de risco para sistematizar o processo de trabalho educativo de equipes de saúde que atuam em unidades de urgência e emergência. Métodos: trata-se de um estudo descritivo, do tipo relato de experiência referente a produção de uma tecnologia educacional, desenvolvida entre dezembro de 2019 a novembro de 2020. Resultados: A experiência foi descrita a partir de duas trajetórias: revisão narrativa da literatura e produção da tecnologia educacional. Utilizou-se como estratégia metodológica a produção de tecnologia baseada em evidências. Da revisão narrativa da literatura emergiram sete temas geradores; da produção, materializou-se uma tecnologia educacional, do tipo álbum seriado, com onze páginas, organizado em vinte tópicos, para ser utilizado em unidades de urgência e emergência, com vistas a sensibilizar os usuários sobre a classificação de risco. Conclusão: a produção baseada em evidências de tecnologias educacionais é uma estratégia a ser ampliada na enfermagem, com vistas a sistematizar a assistência de enfermagem de forma segura e com qualidade. (AU)

Objective: to report the production of an educational technology on risk classification to systematize the educational work process of health teams working in urgency and emergency units. Methods: this is a descriptive study, of the experience report type, referring to the production of an educational technology, developed from December 2019 to November 2020. Results: The experience was described from two trajectories: narrative literature review and production of educational technology. The production of evidence-based technology was used as a methodological strategy. From the narrative review of the literature, seven generative themes emerged; After the production, an educational technology was materialized, of the serial album type, with eleven pages, organized in twenty topics, to be used in urgency and emergency units, with a view to sensitizing users about risk classification. Conclusion: evidence-based production of educational technologies is a strategy to be expanded in nursing, with a view to systematizing nursing care safely and with quality. (AU)

Objetivo: informar sobre la producción de una tecnología educativa en clasificación de riesgos para sistematizar el proceso de trabajo educativo de los equipos de salud que trabajan en las unidades de urgencia y emergencia. Metodos: se trata de un estudio descriptivo, del tipo relato de experiencia, referido a la producción de una tecnología educativa, desarrollado de diciembre de 2019 a noviembre de 2020. Resultados: La experiencia se describió a partir de dos trayectorias: revisión de literatura narrativa y producción de tecnología educativa. La producción de tecnología basada en evidencia se utilizó como estrategia metodológica. De la revisión narrativa de la literatura surgieron siete temas generativos; Luego de la producción, se materializó una tecnología educativa, tipo álbum serial, de once páginas, organizadas en veinte temas, para ser utilizadas en unidades de urgencia y emergencia, con miras a sensibilizar a los usuarios sobre la clasificación de riesgo. Conclusión: la producción basada en evidencia de tecnologías educativas es una estrategia a expandir en enfermería, con miras a sistematizar la atención de enfermería de manera segura y con calidad. (AU)