Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
Cad Saude Publica. 2020 Dec 18;36(12):e00223019. doi: 10.1590/0102-311X00223019. eCollection 2020.
The goal was to review the literature on incidents and adverse events and their contributing factors in hospital care, described according to the patient's perspective. A review was carried out of articles published in the MEDLINE, Scopus and LILACS databases between 2008 and 2019. From the 2,686 studies initially found, 167 were pre-selected for reading and then 24 were selected and classified based on a thematic analysis of their content. Four categories resulted from the information extracted from the 24 articles: terminology used to define incidents and adverse events, especially different terms such as error and medical error; incidents and adverse events identified by patients, family members and caregivers related to medication, surgery, health care-related infections, falls and pressure injuries; patients' perception of factors that contribute to unsafe care, especially problems related to communication, hand washing and patient identification; suggestions from patients to prevent the occurrence of incidents and adverse events, including training staff, drawing up checklists, listening to patients and adapting the environment. Patients were able to identify incidents, adverse events and contributing factors in health care. Alongside information from staff, their reports can potentially contribute to the provision of safer health care.
目的是回顾医院护理中事件和不良事件及其促成因素的文献,从患者的角度进行描述。对 2008 年至 2019 年期间在 MEDLINE、Scopus 和 LILACS 数据库中发表的文章进行了综述。从最初发现的 2686 项研究中,预选了 167 项进行阅读,然后根据其内容的主题分析选择了 24 项并进行了分类。从 24 篇文章中提取的信息得出了四个类别:用于定义事件和不良事件的术语,特别是错误和医疗错误等不同术语;患者、家属和护理人员识别出与药物、手术、与卫生保健相关的感染、跌倒和压疮有关的事件和不良事件;患者对导致不安全护理的因素的看法,特别是与沟通、洗手和患者识别有关的问题;患者预防事件和不良事件发生的建议,包括培训员工、制定检查表、倾听患者意见和改善环境。患者能够识别医疗保健中的事件、不良事件和促成因素。除了来自工作人员的信息外,他们的报告还可能有助于提供更安全的医疗服务。