Abstract
To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care. Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital. A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube - removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter - agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury - agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation - weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%). The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.
Highlights
An adverse event (AE) is defined as “an unintentional injury resulting in temporary or permanent disability, prolongation of hospital stay or death, as a consequence of the care provided”(1-2).The National Patient Safety Program (PNSP) implemented by the Ministry of Health in 2013, highlights relevant themes for the investigation of AEs, including the safe use of equipment and material[3].Incidents related to the use of health equipment and devices represent a risk of errors
Considering the above and the worldwide concern with patient safety, the objective of this study was to analyze the occurrence of AEs related to the use of equipment and materials in nursing care, considering the characteristics of the patient/service, type of event, work shift and sector of occurrence of the event, as well as the immediate causes and actions adopted and the degree of harm to the patient
A total of 180 (16.9%) AEs related to the use of equipment and materials in nursing care were identified
Summary
The National Patient Safety Program (PNSP) implemented by the Ministry of Health in 2013, highlights relevant themes for the investigation of AEs, including the safe use of equipment and material[3]. Incidents related to the use of health equipment and devices represent a risk of errors. There are many equipment used in health care, such as infusion pumps, respiratory ventilators, cardioverter/ defibrillator, multiparameter monitor, capnograph, hemodialysis device, among others. A mis-programmed infusion pump may cause a delayed response to therapy or an unexpected or toxic drug reaction; an imprecise respiratory ventilator can cause respiratory instability; a broken defibrillator will prevent the electrical impulse and will not reverse a cardiac arrest; a multi-parameter monitor that is improperly set-up can keep alarms inoperative and generate monitoring errors; overheating can cause burns in patients[4-5]
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