Eventos adversos não infecciosos e quase falhas nos pacientes pediátricos de uma Unidade de Terapia Intensiva em um Hospital Universitário

Abstract

Introduction: The complexity of patient care can increase the risks inherent in hospitalization and the possibility of adverse events, which are defined as injuries resulting from health care, not related to their underlying disease; and near miss (NM), defined as an event that did not reach the patient and caused no harm. The occurrence of adverse events (AEs) and near misses (NM) in pediatric patients is poorly understood. Literature is scarce in reporting "near misses" as the focus is often on adverse events. Objective: To determine the incidence and identify the main types of adverse and near misses events and associated factors in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU) of a university hospital. Method: All patients, clinical or surgical, who were admitted to the PICU from January 1 to December 31, 2014 were included in the study. Excluding patients who were admitted before and after that period, those who remained hospitalized for less 24 hours and those who have not been discharged until December 31 of the year. The active search of cases was carried out, with completion of the Notification of Undesirable Events (FNEI), according to the criteria of the Guidance Manual. The variables investigated were: age: <or = 30 days,> 30 days to 1 year,> 1 to 5 years,> 5 to 10 years and> 10 to 17 years, total time of hospitalization, time elapsed until the first event, adverse event severity score, clinical or surgical treatment, time of occurrence, and categories of professionals involved in adverse and near miss events. Statistical analysis: A descriptive analysis of the data was carried out, where frequencies and proportions were calculated for categorical variables and mean, median, standard deviation and quartiles for continuous variables. The Mann Whitney test, Chi square test and multivariate logistic regression were used. Ethical aspects were considered. RESULTS: Of the 356 patients followed up, 130 presented no event and 226 patients presented 1483 undesirable events, 1231 of which were EA and 252 were NM. The incidence of undesirable events was 63.5% and the mean of 6.6 events per patient. The incidence of AE was 51.7%, mean 5.86 AE / patient and in NM 11.8, mean of 2.54. The majority of AE was related to the use of equipment 83.0%, and the most frequent NMs, 226 (89.7%) were related to the medication. The age group most affected by the events were those younger than one year, as well as the patients in clinical treatment. Near misses were predominantly drug-related, and mostly occurred on the morning shift, and the identified adverse events were more related to equipment and medications and occurred later in the evening and evening. In the first 48 hours of hospitalization, 85.4% of the patients had already experienced AE and / or Near Misses, and 100% after 11 days of hospitalization. The categories of professionals involved in adverse events, mostly, were members of the admirative followed by the nursing team, and near misses doctors. Conclusion: More than half of the patients followed up suffered some type of adverse event and / or almost failure, as early as the first day of hospitalization, and in some cases, more than one event affected the same individual, with more frequent AE equipment and NM medications. Children under one year and those in clinical treatment were more susceptible to AE and NM, the severity score was 1. Administrative professionals were the most involved category in the process. It was verified that the patient's time of permanence in the PICU was directly proportional to the occurrence of events. Knowledge of these data is important for the prevention and safety of hospitalized pediatric patients, as it provides scientific advances, systems analysis, and the development and dissemination of guidelines and standards for practice, using tools to identification and analysis of errors and continuing education.