Adverse events in a psychiatric hospitalization unit

ABSTRACT

Objective

to describe the adverse events found in psychiatric hospitalization, analyzing them in the light of the human error theory.

Method

a qualitative research study, carried out in 2018 in a psychiatric hospital. The data were collected through semi-structured interviews with 15 health professionals from the multidisciplinary team. Analysis was of the lexical type using the Alceste software.

Results

adverse drug events were evidenced due to administration errors or adverse drug reactions, which produce harms such as impregnation and extrapyramidal reactions associated with the risks for falls and bronchoaspiration due to drowsiness and/or sedation. Other harms are related to the patient's aggressiveness, which produce bodily self-harm or harms to another person, such as during a suicide attempt or use of violence as an escape or defense behavior.

Conclusion and implications for the practice

some adverse events are more frequent in psychiatric hospitalization settings; such events need to be known by the mental health team, as they require mitigation actions through the strengthening of patient safety systems. The data subsidize actions for strengthening safety systems in psychiatric hospitalization settings and contribute to reflecting on the concept of patient safety in Psychiatry.

Keywords:
Nursing; Patient Assistance Team; Psychiatric Hospitals; Psychiatry; Patient Safety