Hemovigilância sanitária hospitalar: análise retrospectiva e prospectiva das notificações de incidentes transfusionais imediatos ocorridos em pacientes internados no Hospital das Clínicas da Faculdade de Medicina de Botucatu-UNESP
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Data
2010-09-08
Autores
Alves, Maria Virgínia Martins Faria Faddul [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
A transfusão sanguínea é um processo que mesmo realizado dentro das normas preconizadas, bem indicado e corretamente administrado, envolve risco para os seus usuários. Este estudo foi realizado com o objetivo de conhecer a incidência de incidentes transfusionais imediatos (ITI) em pacientes internados no HC-Unesp Botucatu, investigar o perfil e a causa das ocorrências, e propor melhorias do processo hemoterápico neste hospital, visando a reduzir os riscos e a recorrência dos eventos. Foram pesquisados e analisados todos os ITI ocorridos em pacientes internados nas unidades hospitalares do HC-Unesp Botucatu, no período retrospectivo de março de 2002 a dezembro de 2006, e no período prospectivo de janeiro de 2007 a dezembro de 2007, tendo sido utilizados o banco de notificações de incidentes transfusionais do Projeto Hospitais Sentinela da Anvisa (PHS-Anvisa), em Botucatu – SP, a revisão dos prontuários dos pacientes e a busca ativa de incidentes nas unidades hospitalares. A investigação das causas dos ITI foi baseada na Ficha de Notificação e Investigação de Incidentes Transfusionais da Anvisa (FIT) e na Ficha para Visita de Hemovigilância do PHS-Anvisa, tendo sido analisadas as seguintes variáveis: nº total de ITI ocorridos nos períodos/nº de transfusões realizadas; nº de ITI identificados por busca ativa e por notificação espontânea da comunidade hospitalar; taxa de subnotificações de incidentes; perfil epidemiológico dos pacientes acometidos por ITI, segundo idade, sexo, diagnóstico de entrada e unidade hospitalar de origem; tipo e gravidade do ITI; manifestações clínicas apresentadas pelos pacientes; distribuição dos ITI por causas de origem dos eventos, segundo causas orgânicas, imunológicas ou ocasionadas por falhas humanas, de processos e/ou de infraestrutura do serviço. Nos períodos, retrospectivo e prospectivo do estudo, foram observados...
Blood transfusion is a process that involves risks to users even when performed according to recommended standards, well indicated and correctly administered. This study was performed with the purpose to learn about the incidence of immediate transfusion incidents (ITI) in inpatients at the University Hospital – Unesp Botucatu, investigate the profile and causes of occurrences and propose improvements for the hemotherapeutic process in that hospital. All ITIs occurring to inpatients at the hospitalization units of the University Hospital – Unesp Botucatu were studied and analyzed in the retrospective period from March 2002 to December 2006 and in the prospective period from January 2007 to December 2007. For data collection, the following sources were used: the database for transfusion incident reports of the Sentinel Hospitals Project of Anvisa (PHS-Anvisa) in Botucatu – SP, a review of patients’ medical charts and an active search of incidents at the hospital units. Investigation on ITI causes was based on Anvisa’s Transfusion Incident Investigation and Report Form (FIT) and on the Hemosurveillance Visitation Form of PHS-Anvisa, and the following variables were analyzed: total number of ITIs occurring in the periods/number of transfusions performed; number of ITIs identified by means of active search and spontaneous reporting by the hospital community; incident under-reporting rate; epidemiological profile of patients affected by ITI according to age, gender, diagnosis at hospital admission and hospital unit of origin; ITI type and severity; clinical manifestations shown by patients; ITI distribution of causes originating the events according to organic, immunologic causes or those due to human, process and/or service infrastructure failure. In the retrospective and prospective periods of the study, 238 ITIs (168 and 70 incidents, respectively) were observed among... (Complete abstract click electronic access below)
Blood transfusion is a process that involves risks to users even when performed according to recommended standards, well indicated and correctly administered. This study was performed with the purpose to learn about the incidence of immediate transfusion incidents (ITI) in inpatients at the University Hospital – Unesp Botucatu, investigate the profile and causes of occurrences and propose improvements for the hemotherapeutic process in that hospital. All ITIs occurring to inpatients at the hospitalization units of the University Hospital – Unesp Botucatu were studied and analyzed in the retrospective period from March 2002 to December 2006 and in the prospective period from January 2007 to December 2007. For data collection, the following sources were used: the database for transfusion incident reports of the Sentinel Hospitals Project of Anvisa (PHS-Anvisa) in Botucatu – SP, a review of patients’ medical charts and an active search of incidents at the hospital units. Investigation on ITI causes was based on Anvisa’s Transfusion Incident Investigation and Report Form (FIT) and on the Hemosurveillance Visitation Form of PHS-Anvisa, and the following variables were analyzed: total number of ITIs occurring in the periods/number of transfusions performed; number of ITIs identified by means of active search and spontaneous reporting by the hospital community; incident under-reporting rate; epidemiological profile of patients affected by ITI according to age, gender, diagnosis at hospital admission and hospital unit of origin; ITI type and severity; clinical manifestations shown by patients; ITI distribution of causes originating the events according to organic, immunologic causes or those due to human, process and/or service infrastructure failure. In the retrospective and prospective periods of the study, 238 ITIs (168 and 70 incidents, respectively) were observed among... (Complete abstract click electronic access below)
Descrição
Palavras-chave
Sangue - Tranfusão, Hemotherapeutic process
Como citar
ALVES, Maria Virgínia Martins Faria Faddul. Hemovigilância sanitária hospitalar: análise retrospectiva e prospectiva das notificações de incidentes transfusionais imediatos ocorridos em pacientes internados no Hospital das Clínicas da Faculdade de Medicina de Botucatu-UNESP. 2010. 116 f. Tese (doutorado) - Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, 2010.