RESUMO
OBJETIVO: A compreensão dos eventos adversos facilita a investigação da qualidade da assistência e auxilia na avaliação dos serviços de saúde. O objetivo deste estudo foi identificar os eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva. MÉTODOS: Os dados foram coletados em um impresso próprio, denominado ficha de ocorrências, por um período de dez meses, no qual os pacientes foram monitorados durante o período de internação na unidade. RESULTADOS: Foram registrados 550 eventos adversos sendo: 26 relacionados aos cinco certos na administração de medicamentos, 23 à medicações não administradas, 181 às anotações inadequadas da medicação, 28 à falhas na instalação de drogas em bomba de infusão, 17 à não realização da inalação, 8 ao manuseio incorreto de seringas e agulhas, 53 aos procedimentos de enfermagem não realizados, 46 ao manuseio incorreto de artefatos terapêuticos e diagnósticos, 37 aos alarmes dos equipamentos utilizados de maneira incorreta e 131 à falhas nas anotações de enfermagem. CONCLUSÃO: A existência de eventos adversos no cuidado prestado pela enfermagem são indicadores importantes que evidenciam a qualidade da assistência na unidade de terapia intensiva. Portanto, os eventos adversos devem ser utilizados para subsidiar a educação permanente da equipe de enfermagem.
OBJECTIVE: The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. METHODS: Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. RESULTS: Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. CONCLUSION: The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.
RESUMO
OBJECTIVE: The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. METHODS: Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. RESULTS: Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. CONCLUSION: The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.
