Prevalência e os fatores associados à notificação de eventos adversos em três hospitais de Minas Gerais, MG
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Data
2022-12-12
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Universidade Federal de Viçosa
Resumo
A redução dos eventos adversos (EA) nos serviços de saúde tem sido uma prioridade na saúde pública. O número de EA que acontece no serviço alcança números alarmantes, e poderiam ser evitados. O estudo analisou a prevalência e fatores associados para a ocorrência de EA em três hospitais de Minas Gerais. Estudo quantitativo, transversal e retrospectivo, por meio da análise dos dados das fichas de notificação interna de EA, do período de 2013 a 2020, de três hospitais mineiros. A coleta de dados foi realizada entre 2019 e 2020, por meio de um questionário. As variáveis coletadas foram: ano de ocorrência do evento, motivo da notificação, turno de ocorrência, setor de ocorrência, profissional que executou, incidente associado, manifestações clínicas associadas, ações preventivas e tratamento, gravidade. Todas as informações compiladas foram integradas em um único banco de dados. Para a análise descritiva, as variáveis foram apresentadas como frequências absolutas e relativas. Os dados coletados foram armazenados em no Excel e posteriormente foram analisados pelo software IBM Statistical Package for Social Sciences (SPSS). Foi realizada estatística descritiva de frequência e proporção, e as associações estatísticas por meio do teste do Qui-quadrado de Pearson. Todos os aspectos éticos foram respeitados (CAAE 99312718.3.0000.5153). Encontrou-se 1154 EA. Os anos com maior prevalência foram 2015 (35,6%), 2016 (16,8%) e 2017 (16,2%). A maioria (74,5%) dos EA foi de gravidade leve e a principal causa foi o erro de medicação e fluidos endovenosos (21,8%). Foram considerados associados ao óbito os EA ocorridos em 2018 (p=0,010), em Unidades de Terapia Intensiva/Centros de Terapia Intensiva (p=0,009), em que os pacientes apresentaram parada cardiorrespiratória, taquipneia ou reação alérgica (p<0,001) e necessitaram de alguma intervenção associada à avaliação médica (p=0,039). A prevalência de EA foi alta, predominando erros de medicação e fluídos endovenosos. Os fatores associados foram ano de ocorrência, setor, manifestações clínicas, ações realizadas pela equipe e gravidade do evento. Destaca-se a não completude dos dados nas fichas de notificação, uma limitação do estudo. Importante a realização de capacitação sobre a importância da prevenção e notificação dos EA, de medidas de correções e padronizações, como parte da rotina dos serviços de saúde. Palavras-chave: Dano ao Paciente. Segurança do Paciente. Unidades Hospitalares.
The reduction of adverse events (AE) in health services has been a public health priority. The number of AEs that occur in the health service reaches alarming numbers, and could be avoided. The study analyzed the prevalence and associated factors for the occurrence of AE in three hospitals in Minas Gerais. A quantitative, cross-sectional and retrospective study was carried out, through the analysis of data from internal AE notification forms, from 2013 to 2020, from three hospitals in Minas Gerais. Data collection was carried out between the years 2019 and 2020, through a questionnaire. The variables collected were: year of occurrence of the event, reason for notification, shift of occurrence, sector of occurrence, professional who performed it, associated incident, associated clinical manifestations, preventive actions and treatment, severity. All compiled information was integrated into a single database. For descriptive analysis, variables were presented as absolute and relative frequencies. The collected data were stored in an Excel spreadsheet and subsequently analyzed using the IBM Statistical Package for Social Sciences (SPSS) software. Descriptive statistics were performed using frequency and proportion, and statistical associations were performed using Pearson's chi-square test. All ethical aspects were respected (CAAE 99312718.3.0000.5153). 1154 AE were found. The years with the highest prevalence were 2015 (35.6%), 2016 (16.8%) and 2017 (16.2%). The majority (74.5%) of the events were considered of mild severity and the main cause was medication and intravenous fluid errors (21.8%). Associated with death were AEs that occurred in 2018 (p=0.010), in Intensive Care Units/Intensive Care Centers (p=0.009), in which patients had cardiorespiratory arrest, tachypnea or allergic reaction (p<0.001) and required some intervention associated with medical evaluation (p=0.039). The prevalence of AE was high, with a predominance of medication errors and intravenous fluids. Associated factors were year of occurrence, sector, clinical manifestations, actions taken by the team and severity of the event. It is important to highlight the incompleteness of the data in the notification forms, a limitation of the study. It is important to carry out training on the importance of preventing and reporting AEs, corrective measures and standardization, as part of the routine of health services. Keywords: Patient Harm. Patient safety. Hospital Units.
The reduction of adverse events (AE) in health services has been a public health priority. The number of AEs that occur in the health service reaches alarming numbers, and could be avoided. The study analyzed the prevalence and associated factors for the occurrence of AE in three hospitals in Minas Gerais. A quantitative, cross-sectional and retrospective study was carried out, through the analysis of data from internal AE notification forms, from 2013 to 2020, from three hospitals in Minas Gerais. Data collection was carried out between the years 2019 and 2020, through a questionnaire. The variables collected were: year of occurrence of the event, reason for notification, shift of occurrence, sector of occurrence, professional who performed it, associated incident, associated clinical manifestations, preventive actions and treatment, severity. All compiled information was integrated into a single database. For descriptive analysis, variables were presented as absolute and relative frequencies. The collected data were stored in an Excel spreadsheet and subsequently analyzed using the IBM Statistical Package for Social Sciences (SPSS) software. Descriptive statistics were performed using frequency and proportion, and statistical associations were performed using Pearson's chi-square test. All ethical aspects were respected (CAAE 99312718.3.0000.5153). 1154 AE were found. The years with the highest prevalence were 2015 (35.6%), 2016 (16.8%) and 2017 (16.2%). The majority (74.5%) of the events were considered of mild severity and the main cause was medication and intravenous fluid errors (21.8%). Associated with death were AEs that occurred in 2018 (p=0.010), in Intensive Care Units/Intensive Care Centers (p=0.009), in which patients had cardiorespiratory arrest, tachypnea or allergic reaction (p<0.001) and required some intervention associated with medical evaluation (p=0.039). The prevalence of AE was high, with a predominance of medication errors and intravenous fluids. Associated factors were year of occurrence, sector, clinical manifestations, actions taken by the team and severity of the event. It is important to highlight the incompleteness of the data in the notification forms, a limitation of the study. It is important to carry out training on the importance of preventing and reporting AEs, corrective measures and standardization, as part of the routine of health services. Keywords: Patient Harm. Patient safety. Hospital Units.
Descrição
Palavras-chave
Hospitais - Administração de riscos, Pacientes hospitalizados - Medidas de segurança, Hospitais - Medidas de segurança, Assistência hospitalar
Citação
LOUZADA, Daniele Dias. Prevalência e os fatores associados à notificação de eventos adversos em três hospitais de Minas Gerais, MG. 2022. 80 f. Dissertação (Mestrado em Ciências da Saúde) - Universidade Federal de Viçosa, Viçosa. 2022.