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Revista Brasileira de Terapia Intensiva
On-line version ISSN 1982-4335
BECCARIA, Lucia Marinilza et al. Nursing care adverse events at an intensive care unit. Rev. bras. ter. intensiva [online]. 2009, vol.21, n.3, pp.276-282. ISSN 1982-4335. http://dx.doi.org/10.1590/S0103-507X2009000300007.
OBJECTIVE: The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. METHODS: Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. RESULTS: Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. CONCLUSION: The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.
Keywords : Nursing, team; Errors of medication; Patient care [nursing]; Safety [standards]; Quality of health care; Intensive care.