Accuracy and completeness of records of adverse events through interface terminology

González-Samartino, Maribel; Delgado-Hito, Pilar; Adamuz-Tomás, Jordi; Cano, Maria Fe Viso; Creus, Mònica Castellà; Juvé-Udina, María-Eulàlia

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Original Article • Rev. esc. enferm. USP 52 • 2018 • https://doi.org/10.1590/S1980-220X2017011203306 copy

Accuracy and completeness of records of adverse events through interface terminology

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To determine what adverse events, including pressure ulcers, infection of the surgical site and aspiration pneumonia, nurses record in clinical histories, in terms of diagnostic accuracy and completeness, through ATIC.

Method:

Observational, descriptive, cross-sectional, multicenter study of 64 medical-surgical and semi-critical units of two university hospitals in Catalonia, Spain, during 2015. The diagnostic accuracy was assessed by means of the correspondence between the event declared in the Minimum Basic Data Set and the problem documented by the nurse. The record was considered complete when it contained the risk of the event, prescriptions of care and a record of the evolution.

Results:

The sample evaluated included 459 records. The accuracy results of pressure ulcers are highly correlated between the nursing diagnosis recorded and that declared in the Minimum Basic Data Set. The accuracy in surgical site infection is moderate, and aspiration resulting in pneumonia is very low. The completeness of results is remarkable, except for the risk of bronchoaspiration.

Conclusion:

The adverse event recorded by nurses with greatest accuracy is pressure ulcers.

DESCRIPTORS
Nursing Records; Pressure Ulcer; Surgical Wound Infection; Pneumonia Aspiration; Standardized Nursing Terminology; Patient Safety

Adverse Event reported in MBDS	ATIC Diagnostics
Pressure ulcer	Pressure ulcer grade I
	Pressure ulcer grade II
	Pressure ulcer grade III
	Pressure ulcer grade IV
Surgical site infection	Surgical wound ^* * With orientation of suspicion of infection recorded; presence of signs and symptoms, such as heat, pain, erythema, swelling and/or purulent discharge. Contaminated surgical wound ^* * With orientation of suspicion of infection recorded; presence of signs and symptoms, such as heat, pain, erythema, swelling and/or purulent discharge.
Aspiration Pneumonia Aspiration Pneumonitis	Bronchoaspiration ^ With record of orientation of suspicion of pneumonia after an episode of aspiration; presence of fever and/or purulent secretions. Hypoxemia ^ With record of orientation of suspicion of pneumonia after an episode of aspiration; presence of fever and/or purulent secretions.

		PU (n=153)		SSI (n=153)		AP (n=153)
		n	%	n	%	n	%
Sex	Men	71	46.4	100	65.4	93	60.8
Sex	Women	82	53.6	53	34.6	60	39.2
Type of admission	Urgent	112	73.2	29	19	126	82.4
Type of admission	Scheduled	41	26.8	124	81	27	17.6
Hospitalization area	Medical	127	83	32	20.9	117	76.5
Hospitalization area	Surgical	26	17	121	79.1	36	23.5
Age M (SD)		72.8	(15.3)	64	(15.7)	72.9	(14.3)
Stay M (SD)		38.7	(49)	33.2	(21.7)	29.6	(24.5)

AE	ATIC diagnostics	n	%
PU (n=153)	Pressure injury grade I	25	16.6
	Pressure injury grade II	60	39.2
	Pressure injury grade III	54	35.3
	Pressure injury grade IV	18	11.7
SSI (n=153)	Surgical wound^* * With orientation of suspected signs and symptoms of infection include heat, pain, erythema, swelling and/or purulent discharge.	57	37.2
SSI (n=153)	Contaminated surgical wound ^* * With orientation of suspected signs and symptoms of infection include heat, pain, erythema, swelling and/or purulent discharge.	18	11.7
AP (n=153)	Hypoxemia ^ With orientation of uspected pneumonia after an episode of aspiration; fever and/or purulent secretions.	38	24.8
AP (n=153)	Bronchoaspiration ^ With orientation of uspected pneumonia after an episode of aspiration; fever and/or purulent secretions.	4	2.6

AE	Completeness characteristics		n	%
PU (n=153)	Identification of the risk		149	97.4
	Prescriptions consistent with the diagnosis M (SD)		2.1	(1.9)
	Evolution of care
		Preformulated template	35	22.8
		Progress notes	57	37.2
SSI (n=153)	Identification of the risk		150	98
	Prescriptions consistent with the diagnosis M (SD)		1.3	(1.4)
	Evolution of care
		Preformulated template	52	34
		Progress notes	80	52.3
AP (n=153)	Identification of the risk		21	13.7
	Prescriptions consistent with the diagnosis M (SD)		1.2	(1.8)
	Evolution of care
		Preformulated template	71	46.4
		Progress notes	51	33.3

Communication of the AE		Specific Training					Area of Care
		Yes		No			Medical U.		Surgical U.
		n	%	n	%	p V	n	%	n	%	p V
PU n=153	Diagnosis	66	74.2	23	25.8	0.00	78	87.6	11	12.4	0.08
	Identification of the risk	88	97.8	61	96.8	1.00	123	96.9	26	100	1
	Prescriptions M (SD)	2.5	(1.9)	1.5	(1.6)	0.01	2.2	(1.9)	1.6	(1.8)	0.08
	Evolution templates	37	58.7	15	16.7	0.00	42	33.1	10	38.9	0.37
	Evolution progress notes	63	70	9	14.3	0.00	58	45.7	14	53.8	0.29
SSI n= 153	Diagnosis	61	67.8	14	22.2	0.00	18	24	57	76	0.42
	Identification of the risk	88	97.8	62	94.8	1.00	38	100	112	97.4	0.57
	Prescriptions M (SD)	1.9	(1.3)	0.4	(0.9)	0.00	1.6	(1.4)	1.2	(1.3)	0.120
	Evolution templates	36	40	16	25.4	0.04	6	28.6	46	35.1	0.37
	Evolution progress notes	60	66.7	20	32.3	0.00	70	53.4	10	47.6	0.39
AP n=153	Diagnosis	35	31.8	7	16.3	0.03	30	25.6	12	33.3	0.24
	Identification of the risk	33	30	4	9.3	0.05	28	23.9	9	25	0.52
	Prescriptions M (SD)	1.4	(1.9)	0.7	(1.5)	0.02	1	(1.7)	1.8	(2.1)	0.03
	Evolution templates	62	56.4	9	20.9	0.00	55	47	16	44.4	0.47
	Evolution progress notes	29	26.4	21	48.8	0.07	37	31.6	13	36.1	0.37

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Maribel González Samartino, Hospital Universitario de Bellvitge, Feixa Llarga s/n, 08907 – Barcelona, Spain maribelgonzalez@bellvitgehospital.cat