Análise de causa raiz de acidentes por quedas e erros de medicação em hospital

Root cause analysis and strategies for reducing falls among inpatients in healthcare facilities: A narrative review

Background and Aims

Root Cause Analysis (RCA) is a systematic process which can be applied to analyze fall incidences in reactive manner to identify contributing factors and propose actions for preventing future falls. To better understand cause of falls and effective interventions for their reduction we conducted a narrative review of RCA and Strategies for Reducing Falls among Inpatients in Healthcare Facilities.

Methods

In this narrative review, databases including Scopus, ISI Web of Science, Cochrane, and PubMed were searched to obtain the related literature published. Databases were searched from January 2005 until the end of March 2023. The Joanna Briggs Institute (JBI) tool was used for quality assessment of articles. To analyze the data, a five-stage framework analysis method was utilized.

Results

Seven articles that fulfilled the inclusion criteria were identified for this study. All of the selected studies were interventional in nature and employed the RCA method to ascertain the underlying causes of inpatient falls. The root causes discovered for falls involved patient-related factors (37.5%), environmental factors (25%), organizational and process factors (19.6%), staff and communication factors (17.9%). Strategies to reduce falls involved environmental measures and physical protection (29.4%), identifying, and displaying the causes of risk (23.5%), education and culturalization (21.6%), standard fall risk assessment tool (13.7%), and supervision and monitoring (11.8%).

Conclusion

the findings identify the root causes of falls in inpatient units and provide guidance for successful action plan execution. Additionally, it emphasizes the importance of considering the unique characteristics of healthcare organizations and adapting interventions accordingly for effectiveness in different settings.

Root cause qualitative analysis of acute childhood poisonings as a study of sentinel surveillance

Objective: To analyze the root cause of occurrences of severe intoxication in children and adolescents from the perspective of sentinel events. Methods: Observational, retrospective, and qualitative study of a series of cases of seven children and young people with a confirmed clinical picture of intoxication by various agents, treated in a stabilization room of emergency care units or intensive care, and notified to toxicological information and assistance center from January to June 2019. The epidemiological surveillance of sentinel events was used based on a review of hospital documents and in-depth interviews with family members. The Root Cause Analysis (RCA) matrix was used to evaluate the cases and the systematic reconstruction of the cases' antecedents.Results: The age profile of the study population, the pattern of agents and substances involved - poisoning by intentional ingestion in five (71%) cases, indicated critical points and missed opportunities for prevention. The individual and family history analysis indicated as direct causal factors the deviations from norms for preventing poisoning at home or in the family context for all cases.The prevention and health promotion activities in the health services constituted the underlying causes of the occurrences.Conclusion: The root cause analysis identified a deficiency in public policies, but the interface between education, public security, social assistance, economy, and health policies would be preponderant for preventing childhood and youth poisoning.

Effect of Professionalism Level on Tendency to Make Medical Errors in Nurses

AIM

The aim of the present study was to examine the relationship between the occupational professionalism level of hospital nurses and their tendency to make medical errors. This was a descriptive, correlational, and cross-sectional study.

METHOD

The study was conducted between June 2013 and January 2015 in four hospitals providing general diagnosis, treatment, and care services. Four hundred fifty-nine nurses were included in the study. A questionnaire including a Personal Information Form, Professional Manner in Occupation Inventory, and Tendency to Medical Error in Nursing Scale was used to collect data. The study was approved by the hospitals' ethics committees and institutions. Data were analyzed using Cronbach's alpha analysis, frequency and percentage distributions, descriptive statistics, Pearson product-moment correlation coefficient, Dunnett T3 Post Hoc test, simple linear regression analysis, and t-test.

RESULTS

Nurses' occupational professionalism levels were high (M=137.06±15.23), and tendency to medical error levels were low (M=223.24±25.28). The majority of the nurses considered themselves quite professional and had not made any medical errors previously. There was a strong and highly significant negative relationship (p<0.001) between their occupational professionalism and their tendency to medical error. There was a difference between the occupational professionalism levels of nurses who made and did not make an occupational error (p<0.05), as well as significant differences between their tendency to medical error according to their perception of themselves as professionals (p<0.05). The occupational professionalism manner of the nurses was determined to be 30% effective in their tendency to medical error.

CONCLUSION

The occupational professionalism manner of the nurses was found to negatively affect their tendency to medical error.

Work process: a basis for understanding nursing errors

OBJECTIVE

To identify work process-related causes associated with nursing errors reported in newspapers.

METHOD

This was a documentary and qualitative study based on the work process theory and hermeneutic analysis that examined 112 news articles published between 2012 and 2016 in 21 high-circulation Brazilian newspapers, organized and codified using Atlas.ti software.

RESULTS

The causes associated with the reported errors were associated with workforce (lack of professionals and training, turnover, work overload, lack of information, recklessness, negligence, and distraction); work instruments (similar labels or packages, storage, lack of product identification and information, and medical prescriptions); and the object of nursing work (overcrowding and specific characteristics of patient).

CONCLUSION

Analysis of the possible causes of reported errors identified the negative outcomes of nursing work, while also identifying elements of the work process that influenced these results. The findings emphasize the importance of understanding these errors so they can be avoided and of reviewing nursing work conditions to guarantee quality and safety of care.

A predictive model for fall risk in hospitalized adults: A case-control study

AIM

To develop and validate a predictive model for falls in hospitalized adult clinical and surgical patients, assessing intrinsic (i.e. patient-related) and extrinsic factors (i.e. care process-related).

BACKGROUND

To identify factors predictive of falls and enable appropriate management of fall risk it is necessary to understand patient and environmental factors, along with care delivery processes.

DESIGN

A matched case-control study.

METHODS

This study was conducted in the medical and surgical wards of a Brazilian teaching hospital. The sample included 536 patients, with data collected in 2013-2014. Data analysis included descriptive statistics and conditional logistic regression. Cases of patients aged 18 years or older who fell while hospitalized were included. One patient who did not fall during hospitalization, matched by sex, ward and admission date, was selected as a control for each included case.

RESULTS

The SAK Fall Scale (Severo-Almeida-Kuchenbecker) was developed and validated. The scale includes seven variables: disorientation/confusion, frequent urination, walking limitations, lack of caregiver, postoperative status, previous falls and number of medications administered within 72 hr prior to the fall. This scale showed acceptable predictive accuracy.

CONCLUSIONS

The newly developed SAK Fall Scale includes five intrinsic and two extrinsic variables and differs from other predictive scales for falls. The findings of this study are broad and the scale, which is easy to apply, can be used worldwide by nurses in health services. In advanced practice, the testing of a new model for fall risk contributes to preventive interventions and thus has an impact on patient safety.

Posicionamento de gestores e lideranças de enfermagem diante dos erros divulgados na mídia

Resumo OBJETIVO Analisar o posicionamento de gestores e lideranças de enfermagem acerca dos erros de enfermagem divulgados na mídia. METODOLOGIA Estudo qualitativo, retrospectivo, documental, coleta de dados realizada em jornais do Brasil e Portugal, entre 2012 e 2016. Análise realizada no Atlas.ti, utilizando a hermenêutica de Ricoeur fundamentada na Teoria do Agir Comunicativo de Habermas. RESULTADOS Gestores e lideranças destacam as condições de trabalho da enfermagem, e prestaram esclarecimentos quanto à ausência de supervisão e déficits na força de trabalho, seguiram com a abertura de sindicância interna, afastamento do cargo e demissão. As lideranças se posicionaram abrindo Processo Ético Disciplinar, realizando fiscalização, solicitando documentos e questionando acerca dos fatos, assim como repudiando algumas notas divulgadas. CONCLUSÃO As lideranças em enfermagem desempenham papel crucial no momento da divulgação de notícias que envolvem erros assistenciais, a fim de expor uma problemática complexa. Entretanto, isso não tem sido feito de forma eficiente.

Safe patient care in the preparation and administration of medicines

OBJECTIVE To evaluate the compliance with the assistance and the adhesion of nursing professionals for the safe administration of drugs in an Intensive Care Unit of a public hospital in Sergipe, Brazil. METHOD Quantitative, descriptive and cross-sectional study carried out by direct non-participant observation. Data collection performed in 2015. Non-probabilistic sample, for convenience, consisting in the observation of 557 doses of prepared and administered drugs. For data analysis, descriptive statistics were used for data analysis. RESULTS The items classified as safe care were: correct via (85.7%) and correct form (100%). The items classified as undesirable care were: correct patient (33.3%), correct medication (66.67%), correct dose (50%), correct register (33.33%), correct orientation (0%), and correct time (50%). CONCLUSION The practice was evaluated according to Carte's positivity index as undesirable care, considering that six of the eight items had low adhesion. The found weaknesses compromised the whole process of drug administration.

NURSING ERRORS: A STUDY OF THE CURRENT LITERATURE

ABSTRACT Objective: to characterize what the current literature states about nursing errors, with a specific review on how these errors are communicated to society by the media. Method: a qualitative documental research, characterized as an integrative literature review, performed using four databases and guided by a formal protocol, in the period from 2011 to 2015, by two independent collaborators. The analysis of the studies occurred through the analysis of thematic content articulated with the resources of the Atlas.ti software. Results: 32 studies were analyzed and organized into two macro categories: main errors practiced by the nursing team; reported forms of prevention to avoid errors. Such categories reveal that most of the errors are made with medication, the main causes are related to work overload and management problems, and the main sources of prevention are to improve working conditions, continuing education and safety culture. Conclusion: nursing errors are determined by multiple factors and their coping requires professional and institutional measures.