Segurança do paciente no centro cirúrgico e qualidade documental relacionadas à infecção cirúrgica e à hospitalização Translated title: Patient safety in the operating room and documentary quality related to infection and hospitalization

Abstract

Objetivo Descrever a qualidade documental de dois registros relacionados à segurança de pacientes no centro cirúrgico e estabelecer as diferenças nas informações relacionadas à infecção cirúrgica e à permanência hospitalar. Métodos Estudo comparativo baseado em dois cortes transversais, realizado com 3.033 pacientes internados há mais de 24 horas, advindos de Cirurgia Ortopédica e Traumatologia. Foram comparados dados sociodemográficos, clínicos e de preenchimento. Mediu-se a infecção pós-cirúrgica como um evento adverso. Resultados Houve correlação significativa entre os dias de hospitalização e o número total de diagnósticos coletados (Pearson=0,328; p<0,001). Quando se agruparam os diagnósticos e a infecção, notou-se um valor significativo entre as fraturas fechadas e a infecção (p=0,001). Conclusão Foram observadas diferenças no grau de preenchimento entre os dois registros. Não houveram diferenças no evento adverso.

Translated abstract

Objective To describe the documentary quality of two records related to patient safety in the operating room and to identify differences between information related to infection and hospitalization. Methods Comparative study based on two cross sections, conducted with 3,033 patients who had been hospitalized for more than 24 hours in an Orthopedics and Traumatology Center. Sociodemographic and clinical data, as well as information provided in forms were compared. Postoperative infection was identified as an adverse event. Results There was a significant correlation between hospitalization days and the total number of diagnoses collected (Pearson=0.328; p<0.001). When diagnoses and infections were grouped together, a significant value was found between closed fractures and infection (p=0.001). Conclusion Differences in the degree of completion were observed between the two records. There were no differences between adverse events.