Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil.
Universidade Federal do Rio Grande do Sul, Escola de Enfermagem, Porto Alegre, RS, Brasil.
Rev Lat Am Enfermagem. 2022;30:e3617. doi: 10.1590/1518-8345.5830.3617.
analyze the falls of adult hospitalized patients and their repercussions on the Nursing worker as the second victim.
an exploratory, descriptive and qualitative study conducted in two stages - identification of falls with moderate to severe damage and the modeling of falls using the software Functional Resonance Analysis Method; and analysis of the repercussions on the worker as the second victim by means of semi-structured interviews submitted to Content Analysis, with 21 Nursing workers.
a total of 447 falls of adult patients were identified, 12 of which with moderate to severe damage, occurred in the absence of the companion, while using sleep inducing, hypotensive or muscle strength altering medications. The modeling identified 22 functions related to the Standard Operating Procedure, to the fall prevention protocol and to the post-event actions. Of these, eight presented variability in their execution. In the second step, the categories "The complexity of care to prevent falls" and "Feelings of the second victim" emerged.
falls are complex phenomena and prevention requires involvement of the patient, family and multi-professional team. The professionals involved are second victims and experience feelings of guilt, fear, anguish and helplessness. This study can contribute to the multi-professional spirit and to the early approach to second victims.
分析成年住院患者跌倒及其对护理人员作为第二受害者的影响。
这是一项在两个阶段进行的探索性、描述性和定性研究——第一阶段识别中度至重度损伤的跌倒，并使用功能共振分析方法软件对跌倒进行建模；第二阶段通过半结构化访谈对工人作为第二受害者的影响进行分析，共 21 名护理人员接受了访谈。
共识别出 447 例成年患者跌倒，其中 12 例为中度至重度损伤，发生在无陪护人员的情况下，同时使用镇静、降压或改变肌肉力量的药物。模型确定了与标准操作程序、跌倒预防协议和事件后行动相关的 22 项功能。其中八项在执行方面存在差异。在第二步中，出现了“预防跌倒的护理复杂性”和“第二受害者的感受”两个类别。
跌倒现象复杂，预防需要患者、家属和多专业团队的参与。相关专业人员是第二受害者，他们会感到内疚、恐惧、痛苦和无助。本研究有助于培养多专业精神和早期关注第二受害者。
