Abstracts
Objective:
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
Objetivo:
identificar as publicações científicas sobre os eventos adversos na assistência de enfermagem em pacientes adultos hospitalizados e discutir os principais eventos adversos na assistência de enfermagem.
Método:
Revisão integrativa com abordagem qualitativa. Os dados foram coletados nas bases LILACS, MEDLINE, BDENF e na biblioteca SCIELO, e submetidos à análise temática.
Resultados:
emergiram três categorias: eventos adversos na assistência de enfermagem; principais causas dos eventos adversos na assistência de enfermagem; o posicionamento da equipe de enfermagem frente ao evento adverso. Identificou-se os principais eventos na assistência de enfermagem, destacando-se os erros na administração de medicação, não realização de curativos e as quedas. Salienta-se a importância dos instrumentos de notificação de eventos adversos nas instituições, porém o medo dos profissionais acerca da punição poderá estimular a subnotificação.
Conclusão:
é importante discutir estratégias de prevenção de eventos realmente eficazes, que assegurem a segurança do paciente nas instituições de saúde.
Segurança do Paciente; Erros Médicos; Cuidados de Enfermagem
Objetivo:
identificar publicaciones científicas sobre los eventos adversos en la atención de enfermería en pacientes adultos hospitalizados y discutir los principales eventos adversos en la atención de enfermería.
Método:
revisión integrativa con un enfoque cualitativo. Los datos fueron recolectados en las bases LILACS, MEDLINE, BDENF y en la biblioteca y analizados con base en el análisis temático.
Resultados:
tres categorías fueron desarrolladas: Los eventos adversos en la atención de enfermería, Las principales causas de los eventos adversos en la atención de enfermería y La postura de los profesionales de enfermería frente a los errores. Fueron identificados los principales eventos en los cuidados de enfermería, destacando el error de medicación, el incumplimiento de los apósitos y las caídas. Destacamos la importancia de los instrumentos para la notificación de eventos adversos en las instituciones. Sin embargo, el temor al castigo de los profesionales estimula el subregistro de los hechos.
Conclusión:
es importante discutir las estrategias de prevención de eventos realmente eficaces, garantizando la seguridad de los pacientes en las instituciones de atención de salud.
Seguridad del Paciente; Errores Médicos; Atención de Enfermería
INTRODUCTION
Discussions about patient safety in hospitals constitute a global trend and the topic has often been approached by the media.
The publication of the Institute of Medicine (IOM) report, To Err is Human: Building
a Safer Health Care System in the late 1990s demonstrated through the analysis of
large epidemiological studies the high incidence of adverse events in hospitals,
often caused by human error, becoming undeniable the need to rethink health care
models used in order to ensure patient safety(11 Kohn LT, Corrigan JM, Donaldson MS, Committee on Quality of Health Care
in America, Institute of Medicine. To err is human: building a safer health system
[Internet]. Whashington: National Academy Press; 2000 [cited 2011 September 12].
Available from: http://www.nap.edu/catalog/9728.html
http://www.nap.edu/catalog/9728.html...
).
Given the global impact of this publication, the World Health Organization (WHO)
created a working group to evaluate patient safety in health services in 2004, the
World Alliance for Patient Safety. The fundamental approach of the Alliance is to
prevent harm to patients and the central element action is called "Global Challenge",
which periodically launches a prior-ity issue to be addressed and a progress
report(22 Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária.
Estratégias para segurança do paciente em hospitais e clínicas [Internet]. Brasília
(DF): Ministério da Saúde; 2010 [acesso em 12 de setembro de 2011]. Disponível em:
www.anvisa.gov.br
www.anvisa.gov.br...
).
In Brazil, discussions on the topic began in 2002 with the creation of the Brazilian
Sentinel Hospital Network by the Brazilian Health Surveillance Agency (ANVISA), which
has voluntary participation and aims to notify adverse events and technical defects
related to technical surveillance, pharmacovigilance and
hemovigilance(22 Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária.
Estratégias para segurança do paciente em hospitais e clínicas [Internet]. Brasília
(DF): Ministério da Saúde; 2010 [acesso em 12 de setembro de 2011]. Disponível em:
www.anvisa.gov.br
www.anvisa.gov.br...
).
Based on the Network experience, in 2013, the Brazilian National Patient Safety
Program (NPSP), established by Decree No. 529/13, the Ministry of Health and the
Collegiate Board Resolution (CBR) 36/2013, estabbolishing actions to patient safety
in health services. Both programs developed the Patient Safety Center (PSC) in health
services through the implementation of Patient Safety Plan (PSP) in Health
Care(33 Ministério da Saúde (BR). Portaria nº. 529, de 1 de abril de 2013.
Institui o Programa Nacional de Segurança do Paciente (PNSP) [Internet]. Diário
Oficial da União 1 abr 2013 [acesso em 02 de abril de 2014]. Disponível em:
http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html
http://bvsms.saude.gov.br/bvs/saudelegis...
-44 Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária.
Resolução da Diretoria Colegiada – RDC nº. 36, de 25 de julho de 2013. Institui ações
para a segurança do paciente em serviços de saúde e dá outras providências
[Internet]. Diário Oficial da União 2013[acesso em 02 abril 2014]. Disponível em:
http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2013/rdc0036_25_07_2013.html
http://bvsms.saude.gov.br/bvs/saudelegis...
).
Despite all the advances in the context of patient safety, however, human error is one of the facts that stands out. Often, errors involving health professionals in hospitals are reported in the press and the media, causing great social pressure.
For the involved staff, the lack of understanding about the error can cause feelings of shame, guilt and fear, given the strong punitive culture that still exists in some institutions, which also contributes to the omission of such episodes.
Error or incident can be defined as the event or circumstance which could have
resulted or resulted in unnecessary harm to the patient, it may be from intentional
or unintentional acts. When these errors do not reach patients, or are detected
beforehand, they are called "near miss"; when they happen but do not cause
discernible harm, they are called incidents without harm, and when they result in
discernible harm, these errors are called incidents with harm or adverse
event(55 World Health Organization. Patient safety research: introductory course
- Session 1. What is patient safety? [place unknown]: WHO; 2012 [cited 2014 July 15].
Available from:
http://www.who.int/patientsafety/research/online_course/en/.
http://www.who.int/patientsafety/researc...
).
Adverse events are the simplest way to recognize the error quantitatively because
they cause harm and are more easily identified, affecting on average 10% of hospital
admissions(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...
). The
occurrence of these events reflects the gap between the actual care and optimal care,
a fact demonstrated by the IOM report, where it was identified that about 44,000 to
98,000 Americans die annually as a result of medical errors(11 Kohn LT, Corrigan JM, Donaldson MS, Committee on Quality of Health Care
in America, Institute of Medicine. To err is human: building a safer health system
[Internet]. Whashington: National Academy Press; 2000 [cited 2011 September 12].
Available from: http://www.nap.edu/catalog/9728.html
http://www.nap.edu/catalog/9728.html...
).
A study conducted in three teaching hospitals in Rio de Janeiro identified a 7.6% incidence of patients affected by adverse events, 66.7% of these were preventable. The occurrence of adverse events cause harm to patients, increase hospitalization time, mortality and hospital costs(77 Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care. 2009;21(4):279-84.).
Regarding the financial magnitude and length of hospital stay for the adverse event,
another study found that the amount of time spent on hospitalizations is 200.5%
higher in the occurrence of adverse events than in hospitalizations without adverse
events, and the length of hospital stay is, on average, 28.3 days or
more(88 Porto S, Martins M, Mendes W, Travassos C. A magnitude financeira dos
eventos adversos em hospitais no Brasil. Rev Port Saúde Pública [Internet]. 2010
[acesso em 15 de julho de 2014];(10):74-80. Disponível em:
http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=13189860&pident_usuario=0&pcontactid=&pident_revista=323&ty=117&accion=L&origen=elsevierpt%20&web=www.elsevier.pt&lan=pt&fichero=323vVol%20Temat(10)n00a13189860pdf001.pdf
http://apps.elsevier.es/watermark/ctl_se...
).
Nursing is the largest health workforce in Brazil, with an es-timated 1.5 million
working professionals(99 Conselho Regional de Enfermagem de São Paulo (BR). 10 passos para a
segurança do paciente [Internet]. 2010 [acesso em 15 de junho de 2011]. Disponível
em:
http://www.coren-sp.gov.br/sites/default/files/10_passos_seguranca_paciente_0.pdf
http://www.coren-sp.gov.br/sites/default...
). This great quantita-tive of professionals relates to the
necessity of a direct relationship with the category of patient safety and error
prevention strategies.
The creation of the Brazilian Network of Nursing and Patient Safety (REBRAENSP) in
2008, was one of the strategies adopted by groups of nurses to develop coordination
and cooperation between health and education institutions, with the aim of
strengthening quality of nursing care and safety (1010 Cassiani SHB. Enfermagem e a pesquisa sobre segurança dos pacientes.
Acta Paul Enferm [Internet]. 2010 [acesso em 15 de julho 2012];23(6):vii-vii.
Disponível em:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002010000600001
http://www.scielo.br/scielo.php?script=s...
).
For the nursing professional, the occurrence of adverse events can cause various problems, given the emotional stress, ethics precepts and legal punishments to which they are exposed to. Therefore, investments in a culture of safety are important through the dissemination of patient safety concept and a non-punitive discussion of adverse events.
From a managerial point of view, managers of health institutions need to understand
that adverse events are often directly related to system failure, instead of
negligence or incompetence. So, rather than looking for guilty individuals, it is
necessary to identify the existing weaknesses in the process and to adopt preventive
measures(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...
).
Thus, this study has the objective to identify the scientific publications on adverse events in nursing care in adult hospitalized patients and discuss the main adverse events in nursing care.
The study is relevant given the current global discussion about patient safety, as we need to know and understand the occurrence of adverse events in nursing care. The study may also help informing and guiding nurses in care planning and decision-making, seeking adverse events prevention strategies.
METHOD
Integrative review with qualitative approach, following the six recommended steps: 1.
Definition of guiding question; 2. Search and selection of studies in the literature;
3. Definition of information to be extracted from studies; 4. Evaluation of the
studies; 5. Interpretation of results; 6. Presentation of the review and synthesis of
knowledge found(1212 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de
pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto &
Contexto Enferm [Internet]. 2008 [acesso em 15 de julho de 2014];17(4):758-64.
Disponível em: http://www.scielo.br/pdf/tce/v17n4/18.pdf
http://www.scielo.br/pdf/tce/v17n4/18.pd...
). To
guide the study, the following research question was designed: What are the
scientific publications on adverse events in nursing care in adult hospitalized
patients?
To conduct the searches, the descriptors were defined through the Virtual Health Library (VHL) website (http://decs.bvs.br), and the descriptors used were: patient safety, medical errors and nursing. The search was conducted in the databases LILACS, MEDLINE and BDENF, and virtual library SCIELO.
The inclusion criteria were: studies published in Portuguese, Spanish and English, in the period 2010-2014, with full text available for free, regarding field researches and with an adult population, over 18 years old, in the hospital setting. Publications that were not related to the topic of study and duplicity of studies were excluded.
Data collection was conducted in December 2014. The selected studies are arranged by date of publication, the most recent to the oldest. After the full reading, data were categorized according to thematic by content analysis(1313 Bardin L. Análise de conteúdo. 4. ed. Lisboa: Ed.70; 2010.).
RESULTS
We found 263 studies, of which 21 met the inclusion criteria and were grouped into three categories: adverse events in nursing care; the main causes of adverse events in nursing care; attitude of nursing professionals when facing adverse events.
Most studies (42.8%) were conducted in 2011. The main sources of included studies are from Brazil. We highlight the lack of free access to most international journals, one of the inclusion criteria of this study.
The box presented below is a summary of the included studies (Box 1).
Adverse events in nursing care
In this category we could identify the major adverse events in nursing care. For a better understanding, the identified events were categorized as follows: Adverse events related to medication administration; Adverse events related to monitoring of the patient; Adverse events related to the maintenance of skin integrity; Adverse events related to material resources, as shown in Box 2.
Adverse events associated with administration of medications are the most common,
and the likelihood of an individual to go through a hospitalization period free of
the occurrence of these events may vary depending on his/her length of hospital
stay. A study in a municipal institution of Rio de Janeiro followed 112
hospitalized patients and identified this probability at 30, 60 and 100 days
being, respectively, 96%, 93% and 73%. It was found that the risk for adverse
event is related to the length of hospital stay and that this risk can vary
according to the gender of the patient. In shorter periods of hospitalization,
males have a higher survival rate, however, from 30 days of hospitalization the
pattern is reversed(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...
).
Another study conducted in Brasilia on adverse events in the administration of
antibiotics confirms the previous finding. The research identified ten types of
antibiotics in medical prescriptions, with an average of 1.2 antibiotics
prescribed. Among the most common errors were: error in the preparation (87.6%)
and errors in administration time (6.2%)(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...
). In addition to the preparation and
administration error, dispensing and prescribing error was also mentioned in
another study with similar results(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...
).
In a study conducted in a hospital in the Sentinel Network of Rio de Janeiro
State, it was observed that 365 doses of intravenous medications prepared by 35
nursing technicians, error rates were found above 70% in all units. Errors were
grouped into different categories: needle exchange, disinfection of ampoules,
bench cleaning, administration time and wrong dose. The high error rates can
result in compromising the microbiological safety of the procedure, increasing the
chances of harm to the patient and the risk for nosocomial
infections(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...
).
A photographic research conducted in the Medical Clinical Unit of Santa Catarina
identified that packaging, distribution and organization of drugs can cause errors
and consequently cause adverse events in nursing care. Among the results, they
highlighted the large amount of drug leftovers, which is inappropriate, since the
dispensation is individual. They also showed improper storage, with unidentified
drugs, congested and overlapping, making it difficult to locate medicine, besides
that, there were bottles and packages opened (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...
).
The severity of the harm related to medical errors related to medication
administration, a study conducted in a cardiology hospital in Rio de Janeiro
identified the occurrence of hypoglycemia related to the use of insulin or oral
hipogliceminante, coagulation disorders, such as bleeding and bruising, and the
occurrence of arrhythmias due to the abrupt withdrawal of the
drug(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...
).
The adverse events related to the surveillance of the patient, highlighted falls
of the bed and simple falls, loss of catheters, tubes and drains, and unscheduled
extubation. A retrospective study conducted in 2009, in the unit of Surgical
Clinic of an institution in Goias, claimed that there were 264 identified adverse
events, 61.36% were related to loss of catheters, tubes and drains, followed by
falls from bed and from own height (18.56%)(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...
). Falls were also identified in a study
conducted in the operating room, where patients had fallen from the operating
table(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...
).
Corroborating these data, a study conducted in hospitals in the United States
identified as major adverse events related to nursing care: medication errors,
hospital infections and falls(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...
).
Another problem highlighted by the literature are the adverse events related to skin integrity of the patient, as the lack of bed position changes, the inappropriate positioning in bed and the consequent development of pressure ulcers, and lack of proper dressings.
In a study conducted in a hospital in the city of Sao Paulo, out of 100
hospitalizations followed, 65 presented adverse events related to the skin
integrity, and 69.2% related to pressure ulcers, 24.6% other injuries and 6.2%
burns. Such occurrences are even more pronounced in great demand for serious
patients where mainly the structure of the service is compro-mised in terms of
staff numbers, which can be aggravated by the lack of inservice training to handle
these situations(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...
).
Concerning adverse events related to material resources, a sentinel hospital in
the Midwest identified occurrences related to forecasting and provision of
materials, equipment maintenance and presence of animals in the operating room,
which led to the suspension of operations, even with the patient anesthetized.
Regarding the consequences of adverse events investigated, 83.9% caused temporary
harm requiring intervention or prolonged hospitalization and 16.1% resulted in
patient death(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...
).
Main causes of adverse events in nursing care
A study conducted in Porto Alegre with the data collected from patient's
statements found an association between the occurrence of medical errors and work
overload. The statements indicated that there were few professionals for the
excessive amount of tasks which generated lack of care in the management of
medicines. Besides that, some prescriptions are unreadable and/or wrong, in
addition to scheduling errors and lack of knowledge of the nursing staff on the
preparation and administration forms(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...
-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...
).
The staff deficit was also demonstrated in a study conducted on the root cause
analysis of adverse events in a hospital in the city of Santiago in Chile. They
also identified deficit in compliance with rules and institutional routines,
nursing supervision deficit and professional inexperience as the main factors that
contributed to the occurrence of adverse events(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...
).
In Sao Paulo, a study identified the factors that can lead to the occurrence of
adverse events in surgical patients, according to the nursing staff: no conference
of patient identification with surgical notice and surgical chart (80.6%), no
conference of materials and equipment used in the procedures (80.7%), medical
staff reprisals when alerting potential issues (71%) and omission of the nursing
team because of the lack of leader autonomy (71%)(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...
).
With regard to the intensive care unit, a study from the state of Sao Paulo found
inadequacies in the allocation of the nursing team, which generated work overload
and adverse events. The occurrence of the events was higher when the allocations
were inadequate, with an average of 1.1 events, compared to the appropriate
allocations, with an average of 0.8 events, highlighting not only the need for
appropriate staff design as well as adjusted working hours according to the hours
of care required by patients(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/...
).
Attitude of nursing professionals when facing adverse events
Nursing staff attitude when facing adverse events may vary according to the institutional and personal cultures (punitive or not), and the perception of the occurrence.
Studies seeking to understand the reactions of health professionals when facing
adverse events identified that for nurses and nursing technicians, the error is
unintentional and often the professional does not realize its occurrence. These
professionals also recognize the impossibility of permanent focus on the activity
performed, which discards intentionality when an error occurs. Professionals
reported they always communicate occurrences in order to get help for the
decisions to be taken and mitigate the feelings of insecurity and
stress(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...
,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....
,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....
).
The recognition of adverse events and other events may also be related to culture,
belief and knowledge of professionals about the problem, as some professionals
have difficulty perceiving the error(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...
,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....
,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....
).
A study on the perception of nursing technicians of adverse events noted that most
professionals communicate the event to the nurse, regardless of the decision to be
taken. Participants stressed the importance of taking responsibility for the
occurrence, stimulating the development of an institutional environment that
eliminates the punitive culture(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...
).
It was also possible to identify the growing adherence of the nursing staff to the
adverse event notification tools. The small amount of notifications at the
beginning of the instruments implementation in the institution indicated
disclosure and insufficient information, lack of habit, insecurity and even
resistance to changing their ideas about adverse events. However, the situation
has been changing over time, given the perception of the management conduction of
the institution that focused on correcting processes and minimizing
errors(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...
).
A study on nursing records allowed the professionals to recognize and notify the
adverse event, adopting preventive measures, possible corrections, reducing or
eliminating occurrences, following the development of the actions implemented to
improve health practice. In the studied institution there was no use of adverse
event notification instruments. Thus, its importance and implementation were
highlighted, as such instrument could provide better research data and management
of events, besides the pursuit of safety culture(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...
).
DISCUSSION
The evaluation of care is an important tool in managing health work processes. The
expected quality is achieved when expectations of internal and external clients of
the institution are met. In nursing care, the expectation is to ensure the best
possible outcome in the clinical condition and the severity of patients, with the
lowest rates of complications procedures performance(3333 Beccaria LM, Pereira RAM, Contrin LM, Lobo SMA, Trajano DHL. Eventos
adversos na assistência de enfermagem em unidade de terapia intensiva. Rev Bras Ter
Intensiva [Internet]. 2009 [acesso em 10 de novembro de 2013];21(3):276-82.
Disponível em: http://www.scielo.br/pdf/rbti/v21n3/a07v21n3.pdf
http://www.scielo.br/pdf/rbti/v21n3/a07v...
).
In this study, we found that adverse events related to medication administration are
the most common, as the nursing team is responsible for implementing the
prescriptions to patients. Such incidents concern hospital managers because they
frequently happen, bringing harm to the patient, representing a professional stigma
and increasing hospitalization costs(3434 Bezerra ALQ, Silva AEBC, Branquinho NCSS, Paranaguá TTB. Análise de
queixas técnicas e eventos adversos notificados em um hospital sentinela. Rev Enferm
UERJ [Internet]. 2009 [acesso em 10 de novembro de 2013];17(4):467-72. Disponível em:
http://www.facenf.uerj.br/v17n4/v17n4a02.pdf
http://www.facenf.uerj.br/v17n4/v17n4a02...
).
Care with fewer errors can be achieved through a change in the method of organizing
work, and the environment in a more active participation of health professionals and
patients towards the reinforcement of user participation on the identification and
prevention of adverse events in the hospital(3535 Schatkoski AM, Wegner W, Algeri S, Pedro ENR. Segurança e proteção à
criança hospitalizada: revisão de literatura. Rev Latinoam Enferm [Internet]. 2009
[acesso em 10 de junho de 2012];18(3):42-50. Disponível em:
http://www.scielo.br/scielo.php?pid=S0104-11692009000300020&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
).
Patients falling from their beds or from own height is another adverse event that
needs to be carefully evaluated, it may cause injuries and consequences to patients,
prolonging the time and costs of hospitalization, with consequent legal liability of
the healthcare team and the institution. It is notewor-thy that the prevention of
falls is an outcome indicator, and is one of the focuses of ANVISA, present in the
PSP, established by CBR 36/2013(44 Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária.
Resolução da Diretoria Colegiada – RDC nº. 36, de 25 de julho de 2013. Institui ações
para a segurança do paciente em serviços de saúde e dá outras providências
[Internet]. Diário Oficial da União 2013[acesso em 02 abril 2014]. Disponível em:
http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2013/rdc0036_25_07_2013.html
http://bvsms.saude.gov.br/bvs/saudelegis...
'2323 Inoue KC, Matsuda LM, Melo WA, Murassaki ACY, Hayakawa LY. Risco de
queda da cama: o desafio da enfermagem para a segurança do paciente. Invest Educ
Enferm [Internet]. 2011 [acesso em 10 maio de 2012];29(3):459-66. Disponível em:
http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-53072011000300015
http://www.scielo.org.co/scielo.php?scri...
).
When procedures such as dressing and changing positions in bed does not occur, the patient is exposed to unsafe care practices, which could delay hospital discharge and his/her return to activities of daily life and, consequently, leading to an increase in hospital costs. Nursing procedures are considered extremely important for the patient, directly influencing the recovery and prevention of hospital infections.
All adverse events identified in the scientific literature through this study can be
classified as preventable, or could be prevented by adopting institutional
strategies. The occurrence of preventable adverse events could not only harm patients
but also cause losses to professionals due to correlated ethical and legal
aspects(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...
).
When errors impair professional's ethics, they appear in the form of incompetence,
carelessness and negligence. Thus, the wrong dilution of a medication is seen as
incompetence, while carelessness occurs when a medication is anticipated, and
negligence occurs when a medication is not checked(3434 Bezerra ALQ, Silva AEBC, Branquinho NCSS, Paranaguá TTB. Análise de
queixas técnicas e eventos adversos notificados em um hospital sentinela. Rev Enferm
UERJ [Internet]. 2009 [acesso em 10 de novembro de 2013];17(4):467-72. Disponível em:
http://www.facenf.uerj.br/v17n4/v17n4a02.pdf
http://www.facenf.uerj.br/v17n4/v17n4a02...
).
It is noteworthy that the daily perception of risk situations contributes to the appropriate management of care with a focus on error prevention and establish safety culture in the institution. Adverse events must be understood in its entirety, considering what exists beyond its occurrence, that is, work overload, lack of professional knowledge, lack of communication, poor institutional infrastructure, among others.
Among the main causes for the occurrence of adverse events, the included studies cited factors inherent to the management of service and nursing care, such as personal deficit, work overload, relationship problems in the multidisciplinary team, lack of leadership and adequate nursing supervision, among others.
In the daily routine of care, it is perceived that the quantitative staff directly influences the implementation of measures to promote adoption of new cultures providing the quality of care. In this context, the dimensioning of nursing staff is a priority for interfering in the administrative process and subsequent care planning.
Complemented to this, one can see that a good performance at work and a good multi
relationship can be decisive in the execution of the work process meeting the needs
of users, articulating spaces and seeking organization of work with a minimum number
of errors(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/...
).
The care planning is a process by which one can achieve results with a minimum number of errors and through dynamic attitudes, that is, depending on the realities found in institutions, considering the uncertainties and unforeseen scenarios of care. In order to achieve this, a leader who deeply knows his/her team's weaknesses and potentialities is necessary.
The communication between its team members, regardless of the channels used, also has
an important impact on the administrative procedure, such as relations between
professionals and patients, because when there is no communication, there is a strong
case for a greater likelihood of adverse events(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...
), which leads to critical thinking that con-firms
the relationship of good clinical practice to an accurate communication.
Communication and leadership are also strongly associated with the orientation and training of staff and are considered important elements not only in socialization, in the training process, but they also help teams to keep a motivational environment, the development of the group and share responsibilities in an integrated way, allowing identification of educational needs, possible failures and the need for adjust-ments for quality of care.
The search for quality in various services offered to society has been increasingly
valued, with the consequent optimization of results. This perspective was
incorporated into the hospitals institutions, with the aim of offering a service of
excellence, reducing costs and ensuring the satisfaction of clients at all levels of
care(3636 Claro CM, Krocockz DVC, Toffolleto MC, Padilha KG. Eventos adversos em
Unidade de Terapia Intensiva: percepção dos enfermeiros sobre a cultura não punitiva.
Rev Esc Enferm USP [Internet]. 2011 [acesso em 10 de novembro de 2013];45(1):167-72.
Disponível em: http://www.scielo.br/pdf/reeusp/v45n1/en_23.pdf
http://www.scielo.br/pdf/reeusp/v45n1/en...
).
In this context, patient safety became valued by modifying the previously used approach in which medical errors were little explored by the institutions. The culture of notification can be the starting point to promote patient safety through real understanding of failures occurred and the implementation of preventive strategies.
The study showed that the nursing staff studied have positioned themselves in favor
of notification of adverse events and the adoption of harm minimization measures.
However, the reporting of adverse events is still neglected, given the existing
punitive culture. There is still great difficulty accepting the error, fearing the
punishment and the incomprehension of the community. The safety culture should be
adapted to legal standards, since safe handling requires change of thoughts and use
of appropriate records, one of the great problems of nursing
practice(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...
,3737 Assunção RC, Dalri MCB. Avaliação dos aspectos éticos e legais dos
registros de enfermagem. Ciênc Cuid Saúde [Internet]. 2010 [acesso em 10 de novembro
de 2013];9(4):676-81. Disponível em:
http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/13812/7184
http://www.periodicos.uem.br/ojs/index.p...
-3838 Martínez Ques AA, Hueso Montoro C, Gálvez Gonzáles MG. Fortalezas e
ameaças em torno da segurança do paciente segundo a opinião dos profissionais de
enfermagem. Rev Latinoam Enferm [Internet] 2010 [acesso em 08 de junho de
2011];18(3):42-50. Disponível em:
http://www.scielo.br/pdf/rlae/v18n3/pt_07.pdf
http://www.scielo.br/pdf/rlae/v18n3/pt_0...
).
Thus, we highlight the need for the adoption of a culture of safety in all institutions, allowing the team to feel safe when reporting errors, since it is only through knowledge about adverse events that it will be possible to understand the situation appropriately, exploring the adoption of truly effective preventive measures.
In nursing, it is essential to understand vulnerability as a principle of its
practice, recognizing all professionals as human beings, and therefore as vulnerable
subjects(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...
).
Understanding that the error can be handled in a positive way with the team reducing
the sense of vulnerability perceived by the professional.
We highlight the responsibility of nursing professionals to communicate and to write
down all their actions completely with reliably, as established by the Nursing Code
of Professional Ethics. We highlight the ethical principles that must be followed by
all professionals as: benevolence, truth, justice, competence and loyalty, which
strengthen the efforts for safe practice and respect for patients'
rights(3939 Santos JO, Silva AEBC, Munari DB, Miasso AI. Condutas adotadas por
técnicos de enfermagem após ocorrências de erros de medicação. Acta Paul Enferm
[Internet]. 2010 [acesso em 10 de novembro de 2013];23(3):328-33. Disponível em:
http://www.scielo.br/pdf/ape/v23n3/en_v23n3a03.pdf
http://www.scielo.br/pdf/ape/v23n3/en_v2...
).
FINAL CONSIDERATIONS
The study identified the scientific literature on major adverse events in nursing when caring for hospitalized patients, highlighting the importance of reporting and understanding the causes of the events. The main preventive measure refers to the recognition of occurrences and the search for an organizational safety culture.
Thus, it was shown that nursing team professionals need a better understanding about adverse events as well as the adoption of a non-punitive culture against the adverse event, which will contribute to further notification by the professionals and therefore for the suitable treatment for the occurrences.
When comparing health institutions with the industrial production sectors, we refer to the fact that the errors in industry are also likely to happen, though, there are sophisticated mechanisms so that the final product, which reach the end consumer, is free of any defects. Unfortunately, the same does not always occur in health institutions, where the final product is the direct patient care and there are still few effective mechanisms to prevent errors.
We emphasize the importance of using adverse event notification instruments by the institutions and the adoption of other notification strategies, as they may contribute to the monitoring and control of events and for the development of truly effective preventive measures.
We emphasize the need for stimulating the safety culture, which will allow nurses discussion of prevention strategies to ensure patient safety in healthcare institutions.
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20Souza 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
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21Corbellini 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
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22Silva 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
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23Inoue KC, Matsuda LM, Melo WA, Murassaki ACY, Hayakawa LY. Risco de queda da cama: o desafio da enfermagem para a segurança do paciente. Invest Educ Enferm [Internet]. 2011 [acesso em 10 maio de 2012];29(3):459-66. Disponível em: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-53072011000300015
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24Camerini 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
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25Roque 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
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26Carneiro 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
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27Rodrigues 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
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28Françolin 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
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29Cecchetto 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
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30Paiva 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
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31Pereira 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
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32Raduenz 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
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33Beccaria LM, Pereira RAM, Contrin LM, Lobo SMA, Trajano DHL. Eventos adversos na assistência de enfermagem em unidade de terapia intensiva. Rev Bras Ter Intensiva [Internet]. 2009 [acesso em 10 de novembro de 2013];21(3):276-82. Disponível em: http://www.scielo.br/pdf/rbti/v21n3/a07v21n3.pdf
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34Bezerra ALQ, Silva AEBC, Branquinho NCSS, Paranaguá TTB. Análise de queixas técnicas e eventos adversos notificados em um hospital sentinela. Rev Enferm UERJ [Internet]. 2009 [acesso em 10 de novembro de 2013];17(4):467-72. Disponível em: http://www.facenf.uerj.br/v17n4/v17n4a02.pdf
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35Schatkoski AM, Wegner W, Algeri S, Pedro ENR. Segurança e proteção à criança hospitalizada: revisão de literatura. Rev Latinoam Enferm [Internet]. 2009 [acesso em 10 de junho de 2012];18(3):42-50. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-11692009000300020&script=sci_arttext&tlng=pt
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36Claro CM, Krocockz DVC, Toffolleto MC, Padilha KG. Eventos adversos em Unidade de Terapia Intensiva: percepção dos enfermeiros sobre a cultura não punitiva. Rev Esc Enferm USP [Internet]. 2011 [acesso em 10 de novembro de 2013];45(1):167-72. Disponível em: http://www.scielo.br/pdf/reeusp/v45n1/en_23.pdf
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37Assunção RC, Dalri MCB. Avaliação dos aspectos éticos e legais dos registros de enfermagem. Ciênc Cuid Saúde [Internet]. 2010 [acesso em 10 de novembro de 2013];9(4):676-81. Disponível em: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/13812/7184
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38Martínez Ques AA, Hueso Montoro C, Gálvez Gonzáles MG. Fortalezas e ameaças em torno da segurança do paciente segundo a opinião dos profissionais de enfermagem. Rev Latinoam Enferm [Internet] 2010 [acesso em 08 de junho de 2011];18(3):42-50. Disponível em: http://www.scielo.br/pdf/rlae/v18n3/pt_07.pdf
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39Santos JO, Silva AEBC, Munari DB, Miasso AI. Condutas adotadas por técnicos de enfermagem após ocorrências de erros de medicação. Acta Paul Enferm [Internet]. 2010 [acesso em 10 de novembro de 2013];23(3):328-33. Disponível em: http://www.scielo.br/pdf/ape/v23n3/en_v23n3a03.pdf
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Publication Dates
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Publication in this collection
Jan-Feb 2015
History
-
Received
04 Nov 2014 -
Accepted
20 Jan 2015