Nascimento Camila Cristina Pires, Toffoletto Maria Cecília, Gonçalves Leilane Andrade, Freitas Walkíria das Graças, Padilha Katia Grillo
Hospital Alemão Oswaldo Cruz, Brazil.
Rev Lat Am Enfermagem. 2008 Jul-Aug;16(4):746-51. doi: 10.1590/s0104-11692008000400015.
This quantitative, retrospective study aimed to characterize adverse events (AE) in Intensive Care Units (ICU), Semi-Intensive Care Units (SCU) and Inpatient Units (IU), regarding nature, type, day of the week and nursing professionals / patient ratio at the moment of occurrence; as well as to identify nursing interventions after the event and AE rates. The study was performed at a private hospital in the city of São Paulo, Brazil. Two hundred twenty-nine AE were notified. The predominant events were related to nasogastric tubes (NGT) (57.6%), followed by patient fall (16.6%) and medication errors (14.8%). The nursing professionals /patient ratio at the moment of the event was 1:2 for the ICU, 1:3 for the SCU and 1:4 for the IU. A similar distribution was observed for the other days of the week. The nursing interventions were: repositioning the NGT (83.2%) and communication of the occurrence to the physician in case of medication errors (47.6%) and falls (55.2%). The highest AE rate was related to NGT.
这项定量回顾性研究旨在描述重症监护病房（ICU）、半重症监护病房（SCU）和住院病房（IU）中不良事件（AE）的特征，包括事件发生时的性质、类型、星期几以及护理人员与患者的比例；同时确定事件发生后的护理干预措施及不良事件发生率。该研究在巴西圣保罗市的一家私立医院进行。共报告了229起不良事件。主要事件与鼻胃管（NGT）相关（57.6%），其次是患者跌倒（16.6%）和用药错误（14.8%）。事件发生时，ICU的护理人员与患者比例为1:2，SCU为1:3，IU为1:4。一周中的其他日子也观察到类似的分布情况。护理干预措施包括：重新放置鼻胃管（83.2%），以及在发生用药错误（47.6%）和跌倒（55.2%）时通知医生。不良事件发生率最高的与鼻胃管相关。
