ABSTRACT
Background and Objectives: adverse events are a major public health problem. The purpose of the study was to characterize the main adverse events with harm reported in a teaching hospital in Minas Gerais. Methods: this is a retrospective cross-sectional descriptive study with quantitative approach, which assessed the reports on adverse events, carried out between January 2015 and December 2018. Pearson's chi-square test was applied in order to verify the association between categorical variables. Cramer's measure V was calculated to assess the degree of association between the respective variables. In the observation of statistically significant results, the Z test was applied to compare proportions with adjustments by the Bonferroni method. Results: a total of 445 adverse events were reported, being the highest number in 2018 (61.8%) involving "Abrasion and friction" process (44.7%), which correspond to grades 3 and 4 pressure injuries. Most adverse events were reported by the Emergency Unit (29.2%), and serious harm (7.6%) and deaths (1.3%) were more prevalent in this place. There was a statistically significant association between types of harm and types of incidents (p<0.001), types of harm (p<0.001) and years of occurrence, and also between the harm and the hospital sectors (p=0.003). Conclusion: adverse event reports back institutional risk management by strengthening the patient safety culture.(AU)
Subject(s)
Humans , Quality of Health Care , Patient Safety , Risk Evaluation and MitigationABSTRACT
Introduction. Vancomycin has become the first-line therapy for most infections caused by methicillin-resistant staphylococci.Aim. To evaluate the vancomycin MIC, staphylococcal cassette chromosome mec (SCCmec) types and clonality of coagulase-negative staphylococci (CoNS) isolates recovered from neonates with true primary bloodstream infections (BSI).Methodology. CoNS isolates were prospectively recovered from blood cultures of non-repetitive patients admitted to a neonatal intensive care unit (NICU) in a tertiary-care hospital during a 3-year period. BSI was defined based on established criteria. Micro-organisms were identified phenotypically and by PCR. MIC-values for vancomycin and oxacillin were determined by broth dilution method and E-test. The SCCmec type conferring methicillin resistance was determined by multiplex PCR. The heterogeneous vancomycin (hV) resistance phenotype was screened on brain heart infusion agar containing 4 µg ml-1 of vancomycin. The clonality was investigated by PFGE.Results. Seventy-four CoNS isolates were recovered from blood cultures of neonates during the study period but only 40 (54â%) were associated with true primary BSI. Nine (22.5%) babies died. Staphylococcus epidermidis was the most prevalent species (95â%; 38/40). All S. epidermidis isolates were methicillin-resistant (MR). SCCmec type IV was predominant (55.3â%; 21/38). Most (80.0â%; 32/38) isolates exhibited vancomycin MIC-values of 2-4 µg ml-1 not associated with the SCCmec type or clonality. Sixteen (42.1%) isolates displayed hV resistance. All babies who died were harbouring MR-S. epidermidis exhibiting vancomycin MICs of 2-4 µg ml-1.Conclusion. The findings of this study demonstrated that blood invasive MR-S. epidermidis isolates recovered at NICU tend to show decreased vancomycin susceptibility making therapy of those fragile patients difficult.