Lanzillotti Luciana da Silva, De Seta Marismary Horsth, de Andrade Carla Lourenço Tavares, Mendes Junior Walter Vieira
Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil,
Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz.
Cien Saude Colet. 2015 Mar;20(3):937-46. doi: 10.1590/1413-81232015203.16912013.
The occurrence of avoidable adverse events (AEs) represents a problem of quality of care that is responsible for the increase in monetary and social costs, causing suffering to the patient, their family members and the professional involved. This situation is aggravated when it involves newborns (NBs) with very low birth weights and shorter gestational ages, admitted to neonatal intensive care units (NICU). The scope of this study is to understand more about these incidents and adverse events in NICUs. The article aims to identify the occurrence of incidents, with and without injury that have occurred in NICUs in the literature and correlate this with the gestational age group of the NBs most affected. This is a systematic review of the available literature on incidents, particularly AEs as witnessed in NICUs. This study reveals that the types of incidents that occur in NICUs, with or without injury to the patient, are related to errors or failures in medication use, healthcare-associated infections (HAIs), skin injuries, mechanical ventilation and intravascular catheters. The cause of incidents and adverse events in NICUs are associated with human factors and the outcomes that are most damaging are due to HAIs. Furthermore, the study points out ways to mitigate these occurrences.
可避免不良事件（AE）的发生代表了医疗质量问题，这会导致金钱和社会成本增加，给患者、其家庭成员以及相关医护人员带来痛苦。当涉及入住新生儿重症监护病房（NICU）的极低出生体重和孕周较短的新生儿（NB）时，这种情况会更加严重。本研究的范围是更深入了解NICU中的这些事件和不良事件。本文旨在确定文献中NICU发生的有伤害和无伤害事件，并将其与受影响最严重的NB孕周组相关联。这是对有关NICU中所见事件，特别是不良事件的现有文献的系统综述。本研究表明，NICU中发生的事件类型，无论患者是否受到伤害，都与用药错误或失误、医疗相关感染（HAI）、皮肤损伤、机械通气和血管内导管有关。NICU中事件和不良事件的原因与人为因素相关，而最具破坏性的后果是由HAI导致的。此外，该研究还指出了减轻这些事件发生的方法。
