Factors associated with patient safety incidents among elderly people in intensive care

Barcelos, Renata Afonso; Tavares, Darlene Mara dos Santos

doi:10.1590/1982-0194201700025

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Original Article • Acta Paul Enferm. 30 (2) • Mar-Apr 2017 • https://doi.org/10.1590/1982-0194201700025 linkcopy

Factors associated with patient safety incidents among elderly people in intensive care

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective Verify demographic and clinical factors associated with patient safety incidents among elderly people in intensive care.

Methods Retrospective study of 112 medical records of elderly people admitted to an intensive care unit in 2015. The data were collected from January to June 2016, using: a form for population characterization; the Simplified Acute Physiology Score II; the Charlson Comorbidity Index and the International Classification for Patient Safety; analyzed by multiple linear regression (p < 0.05).

Results Length of stay increased all types of no harm incidents, general adverse events, clinical process/procedure and infection. There was a higher number of nutrition-related no harm incidents among men, and administration-related adverse events among women. The age group of 69 to 70 years increased the number of medication-related no harm incidents. Hospitalization for clinical reasons increased behavior-related no harm incidents, whereas for surgical reasons it boosted the number of infection-related adverse events.

Conclusion Length of stay; sex; age group and hospitalization were associated with increased no harm incidents and adverse events.

Patient safety; Aged; Intensive care units; Safety management; Geriatric nursing

Type	Description of the patient safety incidents considered
Clinical administration	Ho harm incidents; inter-consultations not answered in 24 hours. Adverse events: discharges suspended due to lack of beds for transfer
Clinical process/procedure	No harm incidents due to procedure/treatment/intervention not carried out when indicated or unavailable: procedures or surgeries not carried out or suspended (except due to the patient’s clinical condition); standardized medication not available; various materials not available; not medicated due to lack of medication or materials; not medicated due to not having a nasoenteral tube. No harm incidents due to inadequate or contraindicated procedure/treatment/intervention: vasoactive drugs in peripheral venous catheter; vasoactive drugs in external central catheter; invasive arterial puncture in cyanotic limb; salinized central venous catheter; selective orotracheal tube; indwelling urinary catheter clamped for more than three hours for test collection; disconnection of the parenteral nutrition infusion route during transport; transport to other sectors in an artificial manual breathing unit; sterile procedure not according to protocol due to lack of material; intubation with dental prostheses; surgery scheduled but not performed, due to no fasting; late tracheostomy; sedated in pressure support ventilation mode; no enteral feeding during hemodialysis; enteral feeding administered to patient with lactose intolerance; leakage of lacerating content of the drain onto the skin; obstruction of the tracheal or orotracheal tube due to secretion stoppers. Adverse events related to general care resulting in skin injury due to: pressure; catheters and different devices or their attachment mechanisms; bruises; contact dermatitis; phlebitis; and others. Adverse events due to procedures/treatments/interventions: perforating or penetrating traumas due to procedures; subcutaneous emphysema due to drainage of the chest; postoperative tachydyspnea due to inadequate devices; tachydyspnea due to obstructions of the tracheal or orotracheal tube because of secretion stoppers; cardiac arrest during transport; cardiac arrest after planned extubation; hemorrhage via orotracheal tube after intubation procedure; failure in planned extubation. Other adverse events: bronchoaspiration; hypoglycemia; diarrhea from enteral feeding; oral feeding drainage due to respiratory devices; tachydyspnea due to mechanical ventilator failure or damage; persistent apnea in pressure support ventilation mode.
Documentation	No harm incidents in medical prescriptions: antibiotics and other medications without dilution mode; without time and infusion route; without dose and desired schedule between doses; erasures on the medical prescription; unsigned or unstamped prescriptions; repeated medical observations; duplicates of items; lack of electronic prescription on day of admission. The number of each type was tabulated. No harm incidents in medical progress notes: no medical progress notes during the shift (morning, afternoon and night). No harm incidents in nursing records related to medical prescriptions: checks without signature; medication without checking; lack of explanation for medication not administered; among others. No harm incidents in nursing notes: unstamped reports from nurses, nursing technicians or nursing students; no nursing report from the shift (morning, afternoon or night). Other no harm incidents in nursing notes: no admission record or discharge summary; admission without complete list of invasive devices; changes in flow rate of vasoactive drugs and sedatives not reported; procedures or transport not reported; discharge to ward without transfer time; nasoenteral tube inserted without auscultation test.
Documentation	Other documentation-related no harm incidents: printed forms for release of items from the pharmacy not filled in; lost medical record documents.
Healthcare-associated infection	Adverse events: healthcare-associated infections in the ICU-A after 72 hours of hospitalization, primarily pulmonary, urinary, abdominal, blood, surgical or others. The HICC records were examined for report of infections acquired in the ICU-A.
Medication/IV fluids	No harm incidents: prescription of a drug to which the patient is allergic; medication not dispensed by the pharmacy; antibiotics not administered. Adverse events: adverse drug reactions.
Blood/blood products: cellular products; coagulation factors, albumin, plasma proteins and immunoglobulin	No harm incidents in medical prescriptions: not prescribed, without volume, route, time and schedule to be administered. No harm incidents in nursing monitoring records (checklist): incomplete in sections for sample identification, administration and after administration of the blood product, transfusion reaction, incomplete vital signs, blank nursing progress notes. No harm incidents related to contraindications: blood transfusion with fever.
Nutrition	No harm incidents: late delivery of enteral feeding by the nutrition service; prolonged fasting; no parenteral feeding for an extended length of time; enteral feeding administered to lactose intolerant patient.
Medical devices/equipment	No harm incidents related to loss or removal of devices: invasive arterial catheter, central venous catheter, peripheral venous catheter and indwelling urinary catheter; non-enteral, enteral, nasogastric and orogastric tubes; various drains; orotracheal and tracheostomy cannulae. No harm incidents related to equipment or devices with a failure or damage: in the mechanical ventilator; dialysis equipment; tomography; invasive blood pressure transducer, cracks or leakage in catheters or tubes.
Behavior	No harm incidents: agitation, disorientation/confusion or aggressiveness on the part of the patient. Only those involving the patient were considered.
Patient accidents	Adverse events: fall, shock-related accidents, burns, freezing, drowning, poisoning and corrosive substances, among others.

No harm incidents	Sex^(a) β (p)	Age group^(b) β (p)	Length of stay β (p)	Reason for hospitalization^(c) β (p)	Simplified Acute Physiology Score II β (p)	Charlson Comorbidity Index β (p)
General	0.013(0.35)	0.068(0.061)	0.924(±0.001)	-0.071(0.052)	0.057(0.115)	-0.058(0.116)
Clinical administration	-0.098(0.362)	0.048(0.642)	0.305(0.005)	-0.151(0.151)	0.159(0.128)	-0.016(0.881)
Process/procedure	0.039(0.424)	0.023(0.625)	0.867(≤ 0.001)	-0.072(0.129)	0.028(0.552)	-0.012(0.806)
Documentation	0.010(0.803)	0.075(0.063)	0.907(≤ 0.001)	-0.067(0.100)	0.060(0.134)	-0.066(0.109)
Medication/IV fluids	-0.015(0.869)	0.175(0.043)	0.451(≤ 0.001)	-0.056(0.520)	0.071(0.407)	-0.198(0.026)
Blood/blood products	*	*	*	*	*	*
Nutrition	0.187(0.041)	-0.060(0.495)	0.291 (0.002)	0.015(0.862)	0.160(0.073)	-0.216(0.019)
Devices/equipment	-0.027(0.672)	0.011(0.856)	0.758(≤ 0.001)	-0.118(0.061)	0.061(0.329)	-0.098(0.127)
Behavior	0.115(0.215)	0.088(0.329)	0.321(0.001)	-0.214(0.019)	-0.123(0.174)	-0.015(0.873)

Adverse Events	Sex^(a) β (p)	Age group^(b) β (p)	Length of stay β (p)	Reason for hospitalization^(c) β (p)	Simplified Acute Physiology Score II β (p)	Charlson Comorbidity Index β (p)
General	-0.008(0.847)	-0.020(0.607)	0.911(±0.001)	0.020(0.598)	0.067(0.079)	0.054(0.166)
Clinical administration	-0.259(0.035)	0.054(0.648)	0.069(0.577)	-0.082(0.488)	0.148(0.211)	-0.013(0.913)
Process/procedure	0.006(0.890)	-0.027(0.497)	0.901(±0.001)	-0.010(0.806)	0.060(0.128)	0.054(0.184)
Healthcare-associated infection	-0.016(0.846)	0.010(0.904)	0.529(±0.001)	0.225(0.006)	0.138(0.090)	0.028(0.735)
Medication	-0.102(0.305)	0.095(0.327)	-0.002(0.981)	0.086(0.372)	-0.172(0.076)	0.015(0.876)

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[TFN1001] Source: World Health Organization, 2009.