Eventos adversos en UCI

Abstract

Introduction: Adverse incidents (AI) are ubiquitous and often under-reported in the medical care system including the ICU. Objective: To examine the frequency, category, severity and consequences of AI on every patient in the paedriatric ICU, Padre Hurtado Hospital. Patients and Methods: 2 133 admissions over a 38 month period (1999-2002) were evaluated. An AI was defined as any event which could or did reduce the safety margin of a patient. Using a non-punitive recording system on a prospective cohort, AI were categorized into airway (A), mechanical ventilator (MV), invasive device (ID), drug (D) or others (O). The causes were human error (HE), equipment malfunction (EM) or infrastructure (I), and the severity graded as mayor (MAI) or minor (mAI). Results: 96 episodes occurred in 73 patients, 3,4% of admissions, categorized as ID 44%, D 18%, A 16%, MV 6% and O 13%. MAI were 61%, A was the most prevalent MAI, 27% and 77% of AI were considered avoidable. One child died as a result of category A AI. Conclusions: AI are common, and it is possible to report them. There is no doubt that patient safety can be improved by the proper recognition of an AI.