Adverse events and safety in nursing care

to identify the scientific publications about adverse events in nursing care in adult hospitalized patients and discuss the main adverse events in nursing care.

Method:

Integrative revision with a qualitative approach. The data were collected at LILACS, MEDLINE, BDENF and the library SCIELO and were submitted to thematic analysis.

Results:

three categories were developed: Adverse events in nursing care; The main causes of the adverse events in nursing care; Attitude of nursing professionals in face of errors. The main events were identified in nursing care with emphasis on the medication error, the failure to perform dressings and falls of patients. The importance of instruments was emphasized for notification of adverse events in the institutions. However the fear of punishment on professionals stimulates the underreporting of events.

Conclusion:

it is important to discuss effective prevention strategies that ensure patient safety in healthcare institutions.

Patient Safety; Medical Errors; Nursing Care

Authorship

Sabrina da Costa Machado Duarte CORRESPONDING AUTHOR: Sabrina da Costa Machado Duarte. E-mail: inamachado@globo.com

Universidade Federal do Rio de Janeiro, Anna Nery School of Nursing. Rio de Janeiro-RJ, BrazilUniversidade Federal do Rio de JaneiroBrazilRio de Janeiro, RJ, BrazilUniversidade Federal do Rio de Janeiro, Anna Nery School of Nursing. Rio de Janeiro-RJ, Brazil

Marluci Andrade Conceição Stipp

Marcelle Miranda da Silva

Francimar Tinoco de Oliveira

CORRESPONDING AUTHOR: Sabrina da Costa Machado Duarte. E-mail: inamachado@globo.com

SCIMAGO INSTITUTIONS RANKINGS

Tables

Tables (2)

Thumbnail

Box 1
Studies about adverse event in nursing care for the period 2010 to 2014, Rio de Janeiro, 2014

Thumbnail

Box 2
Main adverse events described in the scientific literature

Box 1 Studies about adverse event in nursing care for the period 2010 to 2014, Rio de Janeiro, 2014

N.	Title	Journal and year of publication	Authors	Study design	Interventions	Outcomes
01	The reasons of the nursing staff to notify adverse events	Rev Lat-am Enfermagem	Paiva MCMS, Popim RC, Melleiro MM, Tronchim DMR, Lima SAM, Juliani CMCM⁽¹⁴14 Paiva MC, Popim RC, Melleiro MM, Tronchim DM, Lima SA, Juliani CM. The reasons of the nursing staff to notify adverse events. Rev Latinoam Enferm [Internet]. 2014 [cited 2014 December 14];22(5):747-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25493669 http://www.ncbi.nlm.nih.gov/pubmed/25493... ⁾	Phenomenological qualitative study N = 31 nursing professionals	Understanding the motivation of nursing professionals for the reporting of adverse events.	Notification of adverse events is a tool to help management of the care.
		2014
02	Improving patient safety: how and why incidences occur in nursing care	Rev Esc Enferm USP	Toffoletto MC, Ruiz XR⁽¹⁵15 Toffoletto MC, Ruiz XR. Improving patient safety: how and whyincidences occur in nursing care. Rev Esc Enferm USP [Internet]. 2013 [cited 2014 December 14];47(5):1098-105. Available from: http://www.scielo.br/pdf/reeusp/v47n5/0080-6234-reeusp-47-05-1098.pdf http://www.scielo.br/pdf/reeusp/v47n5/00... ⁾	Cross-sectional quantitative study N = 18 incidents	Root cause analysis of incidents related to nursing care.	Vulnerable points in the system can lead to adverse events and root cause analysis can identify these points.
		2013
03	Adverse effects in surgical patients: knowledge of the nursing professionals	Acta Paul Enferm	Bohomol E, Tartali JA⁽¹⁶16 Bohomol E, Tartali JA. Eventos adversos em pacientes cirúrgicos: conhecimento dos profissionais de enfermagem. Acta Paul Enferm [Internet]. 2013 [acesso em 15 de julho de 2014];26(4):376-81. Disponível em: http://www.scielo.br/pdf/ape/v26n4/en_v26n4a12.pdf http://www.scielo.br/pdf/ape/v26n4/en_v2... ⁾	Cross-sectional quantitative study N = 31 nursing professionals	The knowledge of the nursing staff on surgical adverse events, responsible causes, notification.	Identified a fragmented view of the nursing staff about patient safety in the studied scenario, where responsibility is not shared by all.
		2013
04	Nursing allocation and adverse events/incidents in intensive care units	Rev Esc Enferm USP	Gonçalves LA, Andolhe R, Oliveira EM, Barbosa RL, Faro ACM, Galloti RMD, Padilha KG⁽¹⁷17 Gonçalves LA, Andolhe R, Oliveira EM, Barbosa RL, Faro ACM, Galloti RMD, et al. Alocação da equipe de enfermagem e ocorrência de eventos adversos: incidentes em unidade de terapia intensiva. Rev Esc Enferm USP [Internet]. 2012 [acesso em 14 de dezembro de 2014];46(n.º esp);71-1. Disponível em: http://www.scielo.br/pdf/reeusp/v46nspe/en_11.pdf http://www.scielo.br/pdf/reeusp/v46nspe/... ⁾	Observational descriptive quantitative study N=46 patients	Relationship between the adequacy of the nursing staff, working hours and the occurrence of adverse events in ICU.	There is a relationship between the allocation of the nursing team and the event occurrences. Under the appropriate allocations average of occurrence was 0.8 and the inadequate 0.9 to 1.6.
		2012
05	Evaluation of adverse drug events in the hospital context	Esc Anna Nery Rev	Roque KE, Melo ECP⁽¹⁸18 Roque KE, Melo ECP. Avaliação dos eventos adversos a medicamentos no contexto hospitalar. Esc Anna Nery Rev Enferm [Internet]. 2012 [acesso em 15 de julho de 2014];16(1):121-7. Disponível em: http://www.scielo.br/pdf/ean/v16n1/v16n1a16.pdf http://www.scielo.br/pdf/ean/v16n1/v16n1... ⁾	Retrospective quantitative study N = 112 patients	Analysis of adverse events compared to the damage.	The events that have compromised the patient's life were recorded in detail, unlike the others.
		2012
06	Nursing care quality and adverse events in US hospitals	J Clin Nurs	Lucero RJ, Lake ET, Aiken LH⁽¹⁹19 Lucero RJ, Lake ET, Aiken LH. Nursing care quality and adverse events in US hospitals. J Clin Nurs [Internet]. 2010 [cited 2014 December 14];19(15-16):2185-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20659198 http://www.ncbi.nlm.nih.gov/pubmed/20659... ⁾	Cross-sectional Quantitative study N = 10 184 nurses and 168 hospitals	Association between the quality of care and the occurrence of adverse events in US hospitals.	The optimization of nursing care contributes to the reduction of adverse events.
		2011
07	Adverse events: instrument for assessing performance of a university hospital surgical center	Rev Enferm UERJ	Souza LP, Bezerra ALQ, Silva AEBC, Carneiro FS, Paranaguá TTB, Lemos LF⁽²⁰20 Souza LP, Bezerra ALQ, Silva AEBC, Carneiro FS, Paranaguá TTB, Lemos LF. Eventos adversos: instrumento de avaliação do desempenho em centro cirúrgico de um hospital universitário. Rev Enferm UERJ [internet]. 2011 [acesso em 14 de dezembro de 2014];19(1):127-33. Disponível em: http://www.facenf.uerj.br/v19n1/v19n1a21.pdf http://www.facenf.uerj.br/v19n1/v19n1a21... ⁾	Retrospective study N=42 adverse events recorded in books and nursing records	Knowledge of adverse events in the operating room.	Adverse events related to the service and care organization, resulting in serious injuries and deaths.
		2011
08	Medication-related adverse events: percepception of nursing aides	Rev Bras Enferm	Corbellini VL, Schilling MCL, Frantz SF, Godinho TG, Urbanetto JS⁽²¹21 Corbellini VL, Schilling MCL, Frantz SF, Godinho TG, Urbanetto JS. Eventos adversos relacionados a medicamentos: percepção de técnicos e auxiliares de enfermagem. Rev Bras Enferm [Internet]. 2011 [acesso em 15 de dezembro de 2014];64(2):241-7. Disponível em: http://www.scielo.br/pdf/reben/v64n2/a04v64n2.pdf http://www.scielo.br/pdf/reben/v64n2/a04... ⁾	Qualitative study N = 10 nursing technicians and assistants	The perception of technicians and assistants on the occurrence of adverse events.	Errors in medication administration were associated with work overload, prescription and misidentification of the patient.
		2011
09	Adverse events in sentinela hospital in the State of Goiás, Brazil	Rev Latino-Am Enfermagem	Silva AEBC, Reis AMM, Mi-asso AI, Santos JO, Cassiani SHB⁽²²22 Silva AEBC, Reis AMM, Miasso AI, Santos JO, Cassiani SHB. Adverse drug events in sentinel hospital in the State of Goiás, Brazil. Rev Latinoam Enferm [Internet]. 2011 [cited 2014 December 15];19(2):378-86. Available from: http://www.scielo.br/pdf/rlae/v19n2/21.pdf http://www.scielo.br/pdf/rlae/v19n2/21.p... ⁾	Descriptive quantitative, retrospective study, N = 242 nursing records	Identification of adverse events through the nursing records.	Records are sources of information about adverse events, risk analysis and implementation of improvements.
		2011
10	Incidence of inhospital adverse events in the state of Rio de Janeiro, Brazil: evaluation of patient medical record	Rev Bras Epidemiol	Pavão ALB, Andrade D, Mendes W, Martins M, Travassos C⁽⁶6 Pavão ALB, Barbosa, DAR, Mendes W, Martins MS, Travassos CMR. Estudo de incidência de eventos adversos hospitalares, Rio de Janeiro, Brasil: avaliação da qualidade do prontuário do paciente. Rev Bras Epidemiol [Internet]. 2011 [acesso em 15 de julho de 2014];14(4):651-61. Disponível em: http://www.arca.fiocruz.br/bitstream/icict/3868/1/Estudo%20de%20incid%C3%AAncia%20de%20eventos%20adversos%20hospitalares.pdf http://www.arca.fiocruz.br/bitstream/ici... ⁾	Retrospective quantitative study N = 1,103 records	Analysis of the quality of medical records and records of adverse events.	The analyzed records had poor quality and lack of important information, particularly in the discharge summary.
		2011
11	Risk of falling out of bed. Nursing's challenge for the patient's safety	Invest Educ Enferm	Inoue KC, Mat-suda LM, Melo WA, Mussaraki ACY, Hayakawa LY(23)	Cross-sectional descriptive and quantitative study N = 1,307 observations	Factors associated with risk of falling.	Need for improvements in nursing care and physical space to reduce the risk of falling.
		2011
12	Patient safety: analysing intravenous medication preparation in a sentinel network hospital in brazil	Texto e Contexto Enferm	Camerini FG, Silva LD⁽²⁴24 Camerini FG, Silva LD. Segurança do paciente: análise do preparo de medicação intravenosa em hospital da rede sentinela. Texto & Contexto Enferm [Internet]. 2011 [acesso em 10 de novembro de 2013];20(1):41-9. Disponível em: http://www.scielo.br/pdf/tce/v20n1/05.pdf http://www.scielo.br/pdf/tce/v20n1/05.pd... ⁾	Cross-sectional quantitative multicenter observational study N = 35 nursing technicians and 365 doses of medication	Observation of the type and frequency of adverse events.	Error rates above 70% in all categories of the study. The errors relate to the potential change of microbiological safety and therapeutic response.
		2011
13	The length of stay and the occurrence of adverse drug: a question of nursing	Esc Anna Nery Rev	Roque KE, Melo ECP⁽²⁵25 Roque KE, Melo ECP. Tempo de internação e a ocorrência de eventos adversos a medicamentos: uma questão de enfermagem. Esc Anna Nery Rev Enferm [Internet]. 2011 [acesso em 10 de novembro de 2013];15(3):595-601. Disponível em: http://www.scielo.br/pdf/ean/v15n3/a22v15n3.pdf http://www.scielo.br/pdf/ean/v15n3/a22v1... ⁾	Retrospective quantitative evaluation study N = 112 records	Evaluation about the occurrence of adverse drug events.	The probability of no adverse event and survival varies according to the length of hospital stay. The longer the time, the greater the chances of occurrence.
		2011
14	Adverse events in the surgical clinic of a university hospital: a tool for assessing quality	Rev Enferm UERJ	Carneiro FS, Bezerra ALQ, Silva AEBC, Souza LP, Paranaguá TTB, Branquinho NCSS⁽²⁶26 Carneiro FS, Bezerra ALQ, Silva AEBC, Souza LP, Paranaguá TTB, Branquinho NCSS. Eventos adversos na clínica cirúrgica de um hospital universitário: instrumento de avaliação da qualidade. Rev Enferm UERJ [Internet]. 2011 [acesso em 10 de novembro de 2013];19(2):204-11. Disponível em: http://www.facenf.uerj.br/v19n2/v19n2a06.pdf http://www.facenf.uerj.br/v19n2/v19n2a06... ⁾	Retrospective quantitative study N=264 medical errorss	Analysis of adverse events in a surgical clinic.	Identification of various events, however, the notification rate was 19.05%, indicating underreporting. Death was the most serious consequence.
		2011
15	Errors in the administration of antibiotics in the intensive care unit of the teaching hospital	Rev Eletronica Enferm	Rodrigues MCS, Oliveira LC⁽²⁷27 Rodrigues MCS, Oliveira LC. Erros na administração de antibióticos em terapia intensiva de hospital de ensino. Rev Eletrônica Enferm [Internet] 2010 [acesso em 10 de novembro de 2013];12(3):511-9. Disponível em: http://www.fen.ufg.br/revista/v12/n3/v12n3a14.htm http://www.fen.ufg.br/revista/v12/n3/v12... ⁾	Descriptive quantitative study N = 35 patients prescriptions	Characterization of errors in the administration of antibiotics.	Identified preventable and avoidable errors in preparation and administration of antibiotics by the nursing team.
		2010
16	Adverse events and tools for improving the assistance safety of nursing	CuidArte Enferm	Françolin L, Gabriel CS, Melo MRAC, Correa JS⁽²⁸28 Françolin L, Gabriel CS, Melo MRAC, Correa JS. Eventos adversos e ferramentas para melhoria da segurança assistencial da enfermagem. CuidArte Enferm [Internet]. 2010 [acesso em 10 de novembro de 2013];4(2):74-9. Disponível em: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=BDENF&lang=p&nextAction=lnk&exprSearch=20565&indexSearch=ID http://bases.bireme.br/cgi-bin/wxislind.... ⁾	Retrospective descriptive quantitative study N=3,220 patients	Knowledge of the adverse events in the daily care and spontaneously reported.	Study conducted comparison of different institutions. However, points out that this comparison was not appropriate because each institution has a different reality.
		2010
17	Iatrogenic or adverse event: perception of nursing staff	Rev Enferm UFPE online	Cecchetto FH, Fachinelli TS, Souza EM⁽²⁹29 Cecchetto FH, Fachinelli TS, Souza EM. Iatrogenia ou evento adverso: percepção da equipe de enfermagem. Rev Enferm UFPE online [Internet]. 2010 [acesso em 10 de novembro de 2013];4(3):1377-83. Disponível em: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=BDENF&lang=p&nextAction=lnk&exprSearch=20362&indexSearch=ID http://bases.bireme.br/cgi-bin/wxislind.... ⁾	Exploratory descriptive qualitative study N = 12 professional nursing	Nursing staff perception facing the experienced events.	Professionals realize the seriousness of the fact communicating occurrences to the team and assuming the responsibilities.
		2010
18	The attitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics	Rev Lat-am Enfermagem	Coli RCP, Anjos MF, Perereira LL⁽¹¹11 Coli RCP, Anjos MF, Pereira LL. The atitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics. Rev Latinoam Enferm [Internet]. 2010 [cited 2014 July 14];18(3):324-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20721419 http://www.ncbi.nlm.nih.gov/pubmed/20721... ⁾	Descriptive qualitative study N = 14 nurses	Position analysis of nurses according to bioethical references.	Nurses positioned themselves recognizing their mistakes and their vulnerabilities.
		2010
19	Adverse events: analysis of a notification instrument used in nursing management	Rev Esc Enferm USP	Paiva MCMS, Paiva SAR, Berti HW⁽³⁰30 Paiva MCMS, Paiva SAR, Berti HW. Eventos adversos: análise de um instrumento de notificação utilizado no gerenciamento de enfermagem. Rev Esc Enferm USP [Internet]. 2010 [acesso em 10 de maio de 2012];44(2):287-94. Disponível em: http://www.scielo.br/pdf/reeusp/v44n2/en_07.pdf http://www.scielo.br/pdf/reeusp/v44n2/en... ⁾	Retrospective descriptive quantitative study N = 826 Event Reporting Adverse Bulletins	Analysis of Adverse Event Reporting Reports as a means of communication between the nursing staff.	Newsletters promote the event ID, provide means of communication and contribute to the work process management.
		2010
20	Conduct of the future nurses in the perspective of medication error	Rev Enferm UFPE online	Pereira CMB, Pereira OB, Carboni RM⁽³¹31 Pereira CMB, Pereira OB, Carboni RM. Conduta do futuro enfermeiro mediante o erro de medicação. Rev Enferm UFPE online [Internet]. 2010 [acesso em 10 novembro de 2013];4(1)113-8. Disponível em: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=BDENF&lang=p&nextAction=lnk&exprSearch=18841&indexSearch=ID http://bases.bireme.br/cgi-bin/wxislind.... ⁾	Exploratory descriptive quantitative study N = 113 nursing students	Perception of the student and his conduct by medication error.	92% of the students had no doubt, however, 68% believed it was necessary to study more and 75% would report the error.
		2010
21	Nursing care and patient safety: visualizing medication organization, storage and distribution with photographic research methods	Rev Latino-Am Enferm	Raduenz AC, Hoffmann P, Radunz V, Dal Sasso GTM, Maliska ICA, Marck PB⁽³²32 Raduenz AC, Hoffmann P, Radunz V, Dal Sasso GTM, Maliska ICA, Marck PB. Nursing care and patient safety: visualizing medication organization, storage and distribution with photographic research methods. Rev Latinoam Enferm [Internet]. 2010 [cited 2012 June 12];18(6):1045-54. Available from: http://www.scielo.br/pdf/rlae/v18n6/02.pdf http://www.scielo.br/pdf/rlae/v18n6/02.p... ⁾	Qualitative photographic study N = 17 professionals and nursing students	Photo analysis for the identification of organization-related errors, packaging, distribution and preparation of drugs.	The results demonstrating the frequent practices were worrying. From the results, the research seeks to improve patient safety.
		2010

Box 2 Main adverse events described in the scientific literature

Types of Adverse Events	Adverse events reported in the literature
Adverse events related to medication administration	Omission of medicines, errors in the preparation of the medication, errors in administration time, inadequate dose of medication and technical administration errors.
Adverse events related to the monitoring of patient	Patient fall from their bed or own height; loss of catheters, tubes and drains.
Adverse events related to the maintenance of skin integrity	Not performing decubitus change; improper positioning of the patient in bed.
Adverse events related to material resources	Lack of equipment; defective equipment.

How to cite

copy

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

Versão para download de PDF

PDF

Português
Inglês

Versões e tradução automática

Versão original do texto

English
Português

Tradução automática

Google Translator
Microsoft Translator

Como citar

RIS

BIBTEX

Outros formatos de citação e exportação:

SciELO - Scientific Electronic Library Online
Rua Dr. Diogo de Faria, 1087 – 9º andar – Vila Clementino 04037-003 São Paulo/SP - Brasil
E-mail: scielo@scielo.org

Leia a Declaração de Acesso Aberto

Métricas

Adverse events and safety in nursing care

PlumX

Mensagem

[1] CORRESPONDING AUTHOR: Sabrina da Costa Machado Duarte. E-mail: inamachado@globo.com