Segurança do paciente: análise de eventos adversos relacionados às quedas de pacientes hospitalizados
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Data
2018-02-23
Autores
Garcia, Danielle da Cruz
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Universidade Estadual Paulista (Unesp)
Resumo
Introdução: Os serviços de Saúde devem promover meios para prestar uma assistência segura e livre de danos, buscando otimizar resultados relacionados a segurança do paciente e a assistência prestada. A confiança transmitida por meio do cuidado seguro torna-se o desejo de todos os envolvidos no processo, seja o paciente, familiares ou profissionais de saúde. As práticas de assistências à saúde aumentam as chances para uma possível ocorrência de um incidente. Dentre os incidentes que podem ocorrer em uma instituição hospitalar, destaca-se o evento adverso relacionado à queda do paciente, que pode causar diversos tipos de danos como leve, moderado e grave, incluindo a morte. A ocorrência destes eventos pode aumentar o tempo de internação e a necessidade de intervenções diagnósticas e terapêuticas, as quais não estavam no planejamento do cuidado inicial, além de acarretar consequências significativas para o sistema de saúde. Além disso, devem ser contabilizados os custos sociais, emocionais e econômicos decorrentes do evento. Objetivo: O presente trabalho teve como objetivo analisar as notificações de eventos adversos relacionados às quedas dos pacientes hospitalizados em hospital universitário do Estado de São Paulo. Método: Trata-se de um estudo transversal, retrospectivo e descritivo, realizado com dados de relatórios gerenciais do Núcleo de Segurança do Paciente de um hospital escola do interior de São Paulo. Foram incluídas as notificações espontâneas da área de Segurança do Paciente relacionadas às quedas, que ocorreram no período de 01 de janeiro de 2016 a dezembro de 2016. A amostra consiste em 121 notificações. Resultados: A análise dos dados permitiu identificar que cerca de um terço das quedas (29,8%) ocorreu entre os idosos, com faixa etária entre 60 e 69 anos. O setor com maior ocorrência foi pronto socorro (30,6%), apresentando índice de queda médio de 7,26 quedas/1000 pacientes – dia, seguido pela enfermaria de neurologia (9,9%), com 2,36 quedas/1000 pacientes-dia. Quedas de macas (12,40%) e camas (32,2%) tiveram maior representatividade para as notificações no período noturno, já as quedas da própria altura aconteceram com maior frequência no período diurno (38,0%), sendo 62,8% dos pacientes não tiveram danos representativos. Conclusão: O trabalho evidenciou a importância e a necessidade do conhecimento das ocorrências de eventos adversos relacionados às quedas, fornecendo subsídios para elaboração do produto: Protocolo Institucional para prevenção do risco de quedas de pacientes hospitalizados bem como para tomada de decisão e adoção de medidas preventivas e corretivas nas unidades hospitalares.
Health services must provide means to supply safe and harmless assistance, seeking to optimize results related to patient safety and care. Confidence from safe care is desirable for everyone involved in the process, patient, family, or healthcare professionals. Health care practices increase the chances of a possible occurrence of an incident. Among the incidents that may occur in a hospital, the adverse event related to patient fall is highlighted, which can cause several types of damage such as mild, moderate and severe, including death. The occurrence of these events may increase hospitalization time and the need for diagnostic and therapeutic interventions, which were not part of the initial care planning, and would have significant consequences for the health system. In addition, social, emotional and economic costs of such events must be accounted for. The present study aimed to analyze reports of adverse events related to falls of hospitalized patients in a university hospital in São Paulo State. This is a cross-sectional, retrospective and descriptive study, carried out with data from management reports from Patient Safety Center of a school hospital in the interior of São Paulo State. We included spontaneous reports from Patient Safety area related to falls, which occurred between January 1, 2016 and December 2016. The sample consists of 121 notifications. Data analysis allowed us to identify that about one third of the falls (29.8%) occurred among the elderly, ages between 60 and 69 years. The highest occurrence was in the emergency room (30.6%), with an average fall rate of 7.26 falls / 1000 patients-day, followed by the neurology ward (9.9%), with 2.36 falls / 1000 patients-day. Falls from stretchers (12.40%) and beds (32.23%) were more representative for notifications at night time, whereas falls from height occurred more frequently in the daytime (38.02%). The severity of such events was classified as mild, severe, moderate and no damages, and 62.8% of the patients had no representative damage. Conclusion: The study evidenced the importance of monitoring the occurrence of adverse events related to falls, since it provided subsidies for elaboration of the product: Institutional Protocol to prevent the risk of falls of hospitalized patients as well as to the Patient Safety Nucleus decision-making and adoption of preventive and corrective measures in hospital units.
Health services must provide means to supply safe and harmless assistance, seeking to optimize results related to patient safety and care. Confidence from safe care is desirable for everyone involved in the process, patient, family, or healthcare professionals. Health care practices increase the chances of a possible occurrence of an incident. Among the incidents that may occur in a hospital, the adverse event related to patient fall is highlighted, which can cause several types of damage such as mild, moderate and severe, including death. The occurrence of these events may increase hospitalization time and the need for diagnostic and therapeutic interventions, which were not part of the initial care planning, and would have significant consequences for the health system. In addition, social, emotional and economic costs of such events must be accounted for. The present study aimed to analyze reports of adverse events related to falls of hospitalized patients in a university hospital in São Paulo State. This is a cross-sectional, retrospective and descriptive study, carried out with data from management reports from Patient Safety Center of a school hospital in the interior of São Paulo State. We included spontaneous reports from Patient Safety area related to falls, which occurred between January 1, 2016 and December 2016. The sample consists of 121 notifications. Data analysis allowed us to identify that about one third of the falls (29.8%) occurred among the elderly, ages between 60 and 69 years. The highest occurrence was in the emergency room (30.6%), with an average fall rate of 7.26 falls / 1000 patients-day, followed by the neurology ward (9.9%), with 2.36 falls / 1000 patients-day. Falls from stretchers (12.40%) and beds (32.23%) were more representative for notifications at night time, whereas falls from height occurred more frequently in the daytime (38.02%). The severity of such events was classified as mild, severe, moderate and no damages, and 62.8% of the patients had no representative damage. Conclusion: The study evidenced the importance of monitoring the occurrence of adverse events related to falls, since it provided subsidies for elaboration of the product: Institutional Protocol to prevent the risk of falls of hospitalized patients as well as to the Patient Safety Nucleus decision-making and adoption of preventive and corrective measures in hospital units.
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segurança do paciente, acidentes por quedas, gestão de qualidade, enfermagem, quedas, patient safety, accidents by falls, quality of care, nursing, falls