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医院不良事件的发生与可预防情况:一项回顾性研究。

Occurrence and preventability of adverse events in hospitals: a retrospective study.

机构信息

Universidade de São Paulo. Ribeirão Preto, São Paulo, Brazil.

Hospital de clínicas de Uberlândia. Uberlândia, Minas Gerais, Brazil.

出版信息

Rev Bras Enferm. 2023 Jul 10;76(3):e20220025. doi: 10.1590/0034-7167-2022-0025. eCollection 2023.

DOI:10.1590/0034-7167-2022-0025
PMID:37436233
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10332367/
Abstract

OBJECTIVES

to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.

METHODS

observational, analytical, retrospective study based on medical records review.

RESULTS

medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.

CONCLUSIONS

this study's results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.

摘要

目的

分析巴西公立医院成年患者中与医疗保健相关的可预防不良事件的发生率。

方法

基于病历回顾的观察性、分析性、回顾性研究。

结果

共评估了 370 份病历,其中 58 份至少发生了一次不良事件。不良事件发生率为 15.7%。不良事件主要与医疗相关感染(47.1%)和操作(24.5%)有关。关于不良事件的严重程度,13.7%为轻度,51.0%为中度,35.3%为重度。99%的不良事件被归类为可预防。急诊患者发生不良事件的风险高出 3.73 倍。

结论

本研究结果表明,可避免的不良事件发生率较高,这突显了在护理实践中需要进行干预。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/f245/10332367/0fb456b0599b/0034-7167-reben-76-03-e20220025-gf01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/f245/10332367/0fb456b0599b/0034-7167-reben-76-03-e20220025-gf01.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/f245/10332367/0fb456b0599b/0034-7167-reben-76-03-e20220025-gf01.jpg

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The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system.爱尔兰不良事件研究-2(INAES-2):爱尔兰医疗体系中不良事件发生率的纵向趋势。
BMJ Qual Saf. 2021 Jul;30(7):547-558. doi: 10.1136/bmjqs-2020-011122. Epub 2021 Jan 12.
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Variation between hospitals and reviewers in detection of adverse events identified through medical record review in Korea.
韩国通过病历审查发现的不良事件在医院和审查者之间的差异。
Int J Qual Health Care. 2020 Nov 9;32(8):495-501. doi: 10.1093/intqhc/mzaa079.
4
Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.医疗保健环境中可预防的患者伤害的发生率、严重程度和性质:系统评价和荟萃分析。
BMJ. 2019 Jul 17;366:l4185. doi: 10.1136/bmj.l4185.
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Adverse drug events identified in hospitalized patients in Brazil by International Classification of Diseases (ICD-10) code listings.通过国际疾病分类(ICD - 10)编码列表在巴西住院患者中识别出的药物不良事件。
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