2015, Number 3
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Rev Mex Enf Cardiol 2015; 23 (3)
Analysis of the factors related to the presence of adverse events in Pediatric Intensive Care Units
Hernández-Cantoral A, Hernández-Zavala M, Barrientos-Sánchez J, Zárate-Grajales RA
Language: Spanish
References: 28
Page: 110-117
PDF size: 215.25 Kb.
ABSTRACT
Introduction: the presence of an adverse event during the process of hospitalization increases morbidity and mortality, longer hospital stay times, costs and deterioration of the quality of care arise.
Objective: to know the frequency of occurrence of the adverse event in pediatric intensive care to identify the intrinsic, extrinsic factors and areas of the system in a public tertiary care hospital.
Material and methods: descriptive, transversal and observational study, for a year from 2013 to 2014, we used an information notice of adverse event taken and adapted from the project of incidents and adverse events in intensive medicine, safety and risk of the sick critic (SYREC 2007).
Results: in total were 105 adverse event, 71% in unit therapy intensive Pediatric, 18% in neonatal intensive care unit and 11% at the unit of cardiovascular intensive care, 62% of the patients presented during their hospitalization an adverse event, 30% presented two adverse event and 8% more than three. More common in males in 50.5% and 22% cardiovascular alterations. 30% of the adverse event occurred within the first 48 hours entering the unit.
Conclusions: know this type of accidents allows to implement strategies to decrease or control the possible causes. For nursing professional it is important to identify these triggers to participate actively in the programs of safety and quality of care.
REFERENCES
Garjón Parra J, Gorricho Mendívil J. Seguridad del paciente: cuidado con los errores de medicación [Internet]. Boletín de Información Farmacoterapéutica de Navarra. 2010 [citado Nov 2015]; 18(3): [aprox. 1 p]. Disponible en: http://www.navarra.es/home_es/Temas/Portal+de+la+Salud/Profesionales/Documentacion+y+publicaciones/Publicaciones+tematicas/Medicamento/BIT/Vol+18/BIT+VOL+18+N3.htm
Alianza mundial para la seguridad del paciente. La investigación en seguridad del paciente. Mayor conocimiento para una atención más segura. Suiza: Organización Mundial de la Salud; 2008.
Estudio nacional sobre los efectos adversos ligados a la hospitalización: ENEAS 2005. Madrid: Ministerio de Sanidad y Consumo; 2006.
Estudio APEAS. Estudio sobre la seguridad de los pacientes en atención primaria de salud. Madrid: Ministerio de Sanidad y Consumo; 2008.
Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, et al. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med. 2006; 32(10): 1591-1598.
Capuzzo M, Nawfal I, Campi M, Valpondi V, Verri M, Alvisi R. Reporting of unintended events in an intensive care unit: comparison between staff and observer. BMC Emerg Med. 2005; 5(1): 3.
Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G et al. Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med. 1993; 21(1): 40-51.
Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995; 23(2): 294-300.
Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AW, Pronovost P. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003; 31(4):1006-11.
Martín MC, Cabré L, Fernández F, Ruiz J, Jover J, Martín C et al. Adverse events in critical ill patients. Intensive Care Med. 2006; 32: S11.
Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington, DC: National Academies Press; 2000.
Herrera-Kiengelher L, Chi-Lem G, Báez-Saldaña R, Torre-Bouscoulet L, Regalado-Pineda J, López-Cervantes M et al. Frequency and correlates of adverse events in a respiratory diseases hospital in Mexico city. Chest. 2005; 128(6): 3900-3905.
Graf J, von den Driesch A, Koch KC, Janssens U. Identification and characterization of errors and incidents in a medical intensive care unit. Acta Anaesthesiol Scand. 2005; 49(7): 930-939.
Bracco D, Favre JB, Bissonnette B, Wasserfallen JB, Revelly JP, Ravussin P et al. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med. 2001; 27(1): 137-145.
The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Suiza: World Health Organization; 2002.
Franco A. La seguridad clínica de los pacientes. Colombia Médica. 2005; 36(2): 130-133.
Osmon S, Harris CB, Dunagan WC, Prentice D, Fraser VJ, Kollef MH. Reporting of medical errors: an intensive care unit experience. Crit Care Med. 2004; 32(3): 727-733.
Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002; 8(4): 316-320.
Incidentes y Eventos Adversos en Medicina Intensiva. Seguridad y Riesgo en el Enfermo Crítico. SYREC 2007. Madrid: Ministerio de Sanidad, Política Social e Igualdad; 2010.
Declaración de Helsinki de la Asociación Médica Mundial. Principios éticos para las investigaciones médicas en seres humanos. Apéndice F. [Consultado el 25 de 05 de 2015]. Disponible en: www.inb.unam.mx/bioetica/documentos/declaracion_helsinki.pdf
Raduenz AC, Hoffmann P, Radunz V, Dal Sasso GT, Marck P, Maliska IC et al. Nursing care and patient safety: visualizing the organization, storage and distribution of medication with photographic research methods. Rev Latino Am Enfermagem. 2010; 18(6): 1045-1054.
Graf J. Do you know the frequency of errors in your intensive care unit? Crit Care Med. 2003; 31(4): 1277-1278.
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Qual Saf Health Care. 2004; 13(2): 145-152.
Diez SM. Infección Nosocomial: Bacteriana Asociada a catéter venoso central y su prevención (Tesis). España: Universidad de Cantabria; 2014.
Estudio IBEAS. Prevalencia de efectos adversos en hospitales de Latinoamérica. Madrid: Ministerio de Sanidad y Política Social; 2010.
Fajardo-Dolci G, Rodríguez-Suárez J, Gallegos-Alvarado M, Córdoba-Ávila MA, Flores-Bravo MC. Percepción de la frecuencia y causas de los eventos adversos por medicación en enfermería. CONAMED. 2009; 14(1): 22-27.
Gaitan-Duarte H, Eslava-Schmalbach J, Rodríguez-Malagón N, Forero-Supelano V, Santofimio-Sierra D, Altahona H et al. Incidencia y evitabilidad de eventos adversos en pacientes Hospitalizados en tres Instituciones Hospitalarias en Colombia, 2006. Rev Salud Publica. 2008; 10(2): 215-226.
Bellomo R, Goldsmith D, Russell S, Uchino S. Postoperative serious adverse events in a teaching hospital: a prospective study. Med J Aust. 2002; 176(5): 216-218.