Hospital Ernesto Dornelles, Centro de Ensino e Treinamento do Sane (CET-SANE), Porto Alegre, RS, Brazil.
Hospital Ernesto Dornelles, Centro de Ensino e Treinamento do Sane (CET-SANE), Porto Alegre, RS, Brazil.
Braz J Anesthesiol. 2021 Mar-Apr;71(2):137-141. doi: 10.1016/j.bjane.2021.02.023. Epub 2021 Feb 19.
Patient safety is a serious public health with serious implications on morbidity, mortality, and quality of life of patients, in addition to negatively affecting the public image of healthcare institutions and professionals. It requires further investigation, especially in specialties lacking published data, such as endoscopy.
To analyze patient safety incidents reported in a gastrointestinal endoscopy unit of a tertiary hospital in southern Brazil.
This retrospective, cross-sectional study quantitatively described patient safety incidents related to endoscopic procedures. The sample consisted of reports of incidents that occurred from 2015 to 2017. The data were descriptively analysed, and the study was approved by the relevant research ethics committee.
Overall, 42,863 endoscopic procedures were performed and 167 reports were submitted in the period, accounting for a prevalence of incidents of 0.38%. Most incidents did not result in unnecessary harm to patients (76.6%). The most prevalent incidents were those related to patient identification, followed by those related to pathology exams, exam reports, gastrointestinal perforations, skin lesions, falls and medication errors. The rate of adverse events (harm to patient) in patients undergoing any endoscopic procedure was 0.06%.
The incidence of unnecessary harm (adverse event) associated with any endoscopic procedure was relatively low in this study. However, the identification of reported incidents is crucial for evaluating and improving the quality of care provided to patients.
患者安全是一个严重的公共卫生问题，对患者的发病率、死亡率和生活质量都有严重影响，此外还会对医疗机构和专业人员的公众形象产生负面影响。这需要进一步调查，特别是在缺乏已发表数据的专业领域，如内窥镜检查。
分析巴西南部一家三级医院的胃肠内窥镜检查单位报告的患者安全事件。
这是一项回顾性、横断面研究，定量描述了与内窥镜手术相关的患者安全事件。样本包括 2015 年至 2017 年期间发生的事件报告。数据进行了描述性分析，研究得到了相关研究伦理委员会的批准。
总体而言，进行了 42863 次内窥镜检查，在此期间提交了 167 份报告，发生率为 0.38%。大多数事件并未给患者带来不必要的伤害（76.6%）。最常见的事件是与患者身份识别有关的事件，其次是与病理检查、检查报告、胃肠道穿孔、皮肤损伤、跌倒和药物错误有关的事件。任何内窥镜检查程序相关的不良事件（对患者造成伤害）的发生率为 0.06%。
在本研究中，与任何内窥镜检查程序相关的不必要伤害（不良事件）的发生率相对较低。然而，报告事件的识别对于评估和改善患者护理质量至关重要。
