Análise dos eventos adversos em uma unidade de terapia intensiva neonatal como ferramenta de gestão da qualidade da assistência de enfermagem

Abstract

The adverse events are not intentional lesions that result in temporary incapacity or permanence and/or prolongation of the permanence time or death as a consequence of the rendered care. In this epidemic type of historical cohort study, it was aimed at to analyze the evolution of the adverse events in an Intensive Neonatal Therapy Unit as managerial strategy for improvement of the nursing quality attendance. The study was developed at a medium private hospital in the Metropolitan area of Belo Horizonte. The data were obtained through information registered in the neonates handbooks interned in the referred Neonates Unit. They were included and accompanied all of the interned neonates in the period of January from 2005 to December 2006 until leaving the hospital. The research project was verified and approved for the Committee of Ethics and Research of de study field, as well as for the Committee of Ethics and Research the Federal University of Minas Gerais. In reference to the obtained results, it was verified, in the studied period, the occurrence of 547 internments. The average of the gestational age and the weight of RN were 35,4 weeks and 2411,2 grams, respectively. The most affected group of children for the adverse events was the premature ends. The adverse events presented in association with the death were intracranial hemorrhage, change traqueal tube and laboratorial septicemia. From these, the ones that get the attention are the intracranial hemorrhage and the laboratorial septicemia that besides being strongly linked to the death, they happen in significant volume inside of Neonates Unit. The studied service, presented indexes of deaths, laboratorial septicemia and intracranial hemorrhage that can be improved by the adoption of managerial actions, such as the implementation of permanent education programs. As a result, it can be affirmed that the found adverse events are susceptible to be controlled. The reduction of the adverse events can happen by the implementation of the team training programs in order to qualify the team technically propitiating the humanization initiatives invigoration of the care in the Neonatal Unit.