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      Notificación de incidentes relacionados con la atención a la salud en un hospital docente Translated title: Notificação de incidentes relacionados à assistência à saúde em um hospital de ensino Translated title: Notification of incidents related to health care in a teaching hospital

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          Abstract

          RESUMEN: Objetivo: Analizar los incidentes relacionados con la atención médica en un hospital docente. Método: Investigación cuantitativa, realizada con base en las notificaciones de incidencias realizadas entre 2016 y 2018. Los datos se procesaron en la versión 12 del programa STATA. Resultados: La incidencia de eventos adversos fue de 3,82 por cada 100 pacientes-día. Las unidades de hospitalización para adultos fueron los lugares con mayor incidencia de incidentes, 57,20%; pacientes adultos, 52,75%; mujeres, 52,9%; negros, 80,01%; solteros, 47,62%; con escolarización baja o nula, el 50,91%, fueron los principales. Las enfermeras fueron los principales notificadores, 80,38%. Flebitis, 27,05%; cirugías, 19,20%; y las caídas, el 17,27%, fueron los incidentes más reportados, cuyos daños fueron clasificados como leves en el 91,52%, pero hubo 03 muertes en el período. Conclusión: El análisis de los incidentes permite destacar la importancia de las notificaciones para la planificación e implementación de medidas que puedan contribuir al fortalecimiento de la cultura de seguridad del paciente.

          Translated abstract

          RESUMO: Objetivo: Analisar os incidentes relacionados à assistência à saúde em um hospital de ensino. Método: Pesquisa quantitativa, realizada a partir das notificações de incidentes realizadas entre 2016 e 2018. Os dados foram processados no programa STATA versão 12. Resultados: A incidência de eventos adversos foi 3,82 por 100 pacientes-dia. As unidades de internação para adultos foram os locais com maior ocorrência de incidentes, 57,20%; os pacientes adultos, 52,75%; do sexo feminino, 52,9%; negros, 80,01%; solteiros, 47,62%; com baixa ou nenhuma escolaridade, 50,91%, foram os principais atingidos. Os enfermeiros foram os principais notificadores, 80,38%. As flebites, 27,05%; cirurgias, 19,20%; e quedas, 17,27%, foram os incidentes mais notificados, cujos danos foram classificados como leves em 91,52%, mas houve 03 óbitos no período. Conclusão: A análise dos incidentes permite destacar a importância das notificações para o planejamento e implementação de medidas que possam contribuir para o fortalecimento da cultura de segurança do paciente.

          Translated abstract

          ABSTRACT: Objective: Analyzing incidents related to health care in a teaching hospital. Method: A quantitative research carried out based on notifications of incidents carried out between 2016 and 2018. The data were processed in STATA version 12. Results: The incidence of adverse events was 3.82 per 100 patient-days. The adult hospitalization units were the main notifiers, 57.20%; adult patients, 52.75%; females, 52.9%; blacks, 80.01%; singles, 47.62%; with low or no schooling, 50.91%, were the main ones. The nurses were the main notifiers, 80.38%. Phlebitis, 27.05%; surgeries, 19.20%; and falls, 17.27%, were the most reported incidents, whose damage was classified as mild in 91.52%, but there were three deaths in the period. Conclusion: The analysis of incidents allows us to highlight the importance of notifications for the planning and implementation of measures that can contribute to the strengthening of the patient safety culture.

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          Most cited references30

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          Reporting of Adverse Events in Published and Unpublished Studies of Health Care Interventions: A Systematic Review

          Background We performed a systematic review to assess whether we can quantify the underreporting of adverse events (AEs) in the published medical literature documenting the results of clinical trials as compared with other nonpublished sources, and whether we can measure the impact this underreporting has on systematic reviews of adverse events. Methods and Findings Studies were identified from 15 databases (including MEDLINE and Embase) and by handsearching, reference checking, internet searches, and contacting experts. The last database searches were conducted in July 2016. There were 28 methodological evaluations that met the inclusion criteria. Of these, 9 studies compared the proportion of trials reporting adverse events by publication status. The median percentage of published documents with adverse events information was 46% compared to 95% in the corresponding unpublished documents. There was a similar pattern with unmatched studies, for which 43% of published studies contained adverse events information compared to 83% of unpublished studies. A total of 11 studies compared the numbers of adverse events in matched published and unpublished documents. The percentage of adverse events that would have been missed had each analysis relied only on the published versions varied between 43% and 100%, with a median of 64%. Within these 11 studies, 24 comparisons of named adverse events such as death, suicide, or respiratory adverse events were undertaken. In 18 of the 24 comparisons, the number of named adverse events was higher in unpublished than published documents. Additionally, 2 other studies demonstrated that there are substantially more types of adverse events reported in matched unpublished than published documents. There were 20 meta-analyses that reported the odds ratios (ORs) and/or risk ratios (RRs) for adverse events with and without unpublished data. Inclusion of unpublished data increased the precision of the pooled estimates (narrower 95% confidence intervals) in 15 of the 20 pooled analyses, but did not markedly change the direction or statistical significance of the risk in most cases. The main limitations of this review are that the included case examples represent only a small number amongst thousands of meta-analyses of harms and that the included studies may suffer from publication bias, whereby substantial differences between published and unpublished data are more likely to be published. Conclusions There is strong evidence that much of the information on adverse events remains unpublished and that the number and range of adverse events is higher in unpublished than in published versions of the same study. The inclusion of unpublished data can also reduce the imprecision of pooled effect estimates during meta-analysis of adverse events.
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            The assessment of adverse events in hospitals in Brazil.

            To evaluate the incidence of adverse events in Brazilian hospitals. Retrospective cohort study based on patient record review. Three teaching hospitals in the State of Rio de Janeiro, Brazil. Random sample (1103) of 27 350 adult patients admitted in 2003. Patients under 18 years old, psychiatric patients and patients whose length of stay was less than 24 hr were excluded, and obstetric cases were included. Incidence of patients with adverse events; proportion of preventable adverse events; number of adverse events per 100 patients and incidence density of adverse events per 100 patient-days. The incidence of patients with adverse events was 7.6% (84 of 1103 patients). The overall proportion of preventable adverse events was 66.7% (56 of 84 patients). The incidence density was 0.8 adverse events per 100 patient-days (103 of 13,563 patient-days). The patient's ward was the most frequent location of adverse events (48.5%). In regard to classification, surgical adverse events were the most frequent ones (35.2%). The incidence of patients with adverse events at the three hospitals was similar to that in international studies. However, the proportion of preventable adverse events was much higher in the Brazilian hospitals.
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              Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study

              Abstract: This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence.
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                Author and article information

                Journal
                eg
                Enfermería Global
                Enferm. glob.
                Universidad de Murcia (Murcia, Murcia, Spain )
                1695-6141
                2021
                : 20
                : 63
                : 180-220
                Affiliations
                [1] Salvador Bahia orgnameUniversidade Federal da Bahia orgdiv1Hospital Universitario Profesor Edgard Santos Brazil valdenirenf@ 123456gmail.com
                Article
                S1695-61412021000300007 S1695-6141(21)02006300007
                10.6018/eglobal.450481
                a2b5d9f6-2ff7-4182-9c47-2ebeeda56aa6

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 International License.

                History
                : 03 March 2021
                : 14 October 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 30, Pages: 41
                Product

                SciELO Spain

                Categories
                Originales

                Nursing,Enfermería,Hospitales de enseñanza,Seguridad del paciente,Eventos adversos,Notificación,Teaching hospitals,Patient safety,Adverse events,Notification,Enfermagem,Hospitais de ensino,Segurança do paciente,Notificação

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