Figueiredo Mirela Lopes de, Silva Carla Silvana de Oliveira E, Brito Maria Fernanda Santos Figueiredo, D'Innocenzo Maria
Universidade Federal de São Paulo, Paulista Nursing School, Postgraduate Program in Health Sciences. São Paulo, Brazil.
Universidade Estadual de Montes Claros, Center for Biological and Health Sciences, Department of Nursing. Montes Claros, Minas Gerais, Brazil.
Rev Bras Enferm. 2018 Jan-Feb;71(1):111-119. doi: 10.1590/0034-7167-2016-0574.
To evaluate the incidents spontaneously notified in a general hospital in Minas Gerais.
Retrospective, descriptive, quantitative study performed at a general hospital in Montes Claros - Minas Gerais State. The sample comprised 1,316 incidents reported from 2011 to 2014. The data were submitted to descriptive statistical analysis using Statistical Package for the Social Sciences version 18.0.
The prevalence of incidents was 33.8 per 1,000 hospitalizations, with an increase during the investigation period and higher frequency in hospitalization units, emergency room and surgical center. These occurred mostly with adult clients and relative to the medication supply chain. The main causes were noncompliance with routines/protocols, necessitating changes in routines and training.
There was a considerable prevalence of incidents and increase in notifications during the period investigated, which requires the attention of managers and hospital staff. Nevertheless, we observed development of the patient safety culture.
评估米纳斯吉拉斯州一家综合医院自发上报的不良事件。
在米纳斯吉拉斯州蒙特斯克拉罗斯市的一家综合医院开展回顾性、描述性、定量研究。样本包括2011年至2014年上报的1316起不良事件。数据采用社会科学统计软件包第18.0版进行描述性统计分析。
不良事件发生率为每1000例住院患者33.8起，在调查期间呈上升趋势，在住院科室、急诊室和手术中心发生率更高。这些不良事件大多发生在成年患者身上，且与药品供应链有关。主要原因是未遵守常规/协议，需要改变常规并进行培训。
在所调查期间，不良事件发生率相当高且上报数量有所增加，这需要管理人员和医院工作人员予以关注。尽管如此，我们观察到患者安全文化有所发展。
