Mendes Walter, Pavão Ana Luiza B, Martins Monica, Moura Maria de Lourdes de Oliveira, Travassos Claudia
Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
Rev Assoc Med Bras (1992). 2013 Sep-Oct;59(5):421-8. doi: 10.1016/j.ramb.2013.03.002. Epub 2013 Sep 12.
To analyze the features of preventable adverse events (AEs) in hospitals inpatient in the State of Rio de Janeiro, in Brazil, in order to identify elements that serve as a substrate for priority actions aimed at improving patient safety.
Analysis of data from a baseline retrospective cohort study to assess the incidence of AEs in a sample of records in three teaching hospitals in the State of Rio de Janeiro to describe the features of preventable AEs.
In a sample of 1,103 patients, were identified 65 preventable AEs of 56 patients who suffered preventable AEs. The healthcare associated infections (HAI) accounted for 24.6% of preventable AEs; surgical complications and/or anesthetic, 20.0%; damages arising from delay or failure in diagnosis and/or treatment, 18.4%, pressure ulcers, 18.4%; damage from complications of venipuncture, 7.7%; damage due to falls, 6.2%; damage as a result of the use of drugs, 4.6%. The preventable AEs were responsible for additional 373 days of hospital stay.
The HAI is the major preventable AEs, as observed in other developing countries. Despite the limitations of the study, the characterization of preventable AEs indicates that known and effective actions available to reduce HAI, such as hand hygiene, to prevent pressure ulcers, to encourage adherence to protocol and clinical guidelines and to create continuing education programs for health professionals, should compose the list of priorities of hospital managers and health professionals involved in the care of hospitalized patients.
分析巴西里约热内卢州医院住院患者可预防不良事件（AE）的特征，以确定可作为旨在改善患者安全的优先行动基础的因素。
对一项基线回顾性队列研究的数据进行分析，以评估里约热内卢州三家教学医院样本记录中AE的发生率，从而描述可预防AE的特征。
在1103名患者的样本中，56名发生可预防AE的患者共出现65起可预防AE。医疗相关感染（HAI）占可预防AE的24.6%；手术并发症和/或麻醉相关并发症占20.0%；诊断和/或治疗延误或失败导致的损害占18.4%；压疮占18.4%；静脉穿刺并发症导致的损害占7.7%；跌倒导致的损害占6.2%；药物使用导致的损害占4.6%。可预防AE导致住院时间额外增加373天。
与其他发展中国家一样，HAI是主要的可预防AE。尽管该研究存在局限性，但对可预防AE的特征描述表明，已知的有效减少HAI的措施，如手卫生、预防压疮、鼓励遵守规程和临床指南以及为卫生专业人员开展继续教育项目，应纳入参与住院患者护理的医院管理人员和卫生专业人员的优先事项清单。
