Objective:To evaluate the actions of patient safety management developed in hospitals, from the perspective of nurses. Method: This is a cross-sectional, descriptive study of the survey type. Participants were seven hospitals, in which seven nurse managers and 49 sector coordinator nurses (n = 56) answered the instrument prepared by the author. Results:The results showed that 100% of hospitals have an adverse event reporting system, 71.4% have a Risk Management Committee and 80% have discussions about the events. There is agreement that these discussions lead to favorable changes for patient safety in the surveyed institutions. The employees' fear of punishment for their faults, and the underreporting of events were the aspects of greatest weakness found. Conclusion: The institutions should develop organizational policies focused on stimulating event notification and on the implementation of measures directed to a non-punitive organizational culture.

Parenteral nutrition therapy is used in patients with a contraindication to the use of the gastrointestinal tract, and infection is one of its frequent and severe complications. The objective of the present study was to detect the presence of biofilms and microorganisms adhering to the central venous catheters used for parenteral nutrition therapy by scanning electron microscopy. Thirty-nine central venous catheters belonging to patients with clinical signs of infection (G1) and asymptomatic patients (G2) and patients receiving central venous catheters for clinical monitoring (G3) were analyzed by semiquantitative culture and scanning electron microscopy. The central venous catheters of G1 presented more positive cultures than those of G2 and G3 (81% vs 50% and 0%, respectively). However, biofilms were observed in all catheters used and 55% of them showed structures that suggested central venous catheters colonization by microorganisms. Approximately 53% of the catheter infections evolved with systemic infection confirmed by blood culture. The authors conclude that the presence of a biofilm is frequent and is an indicator of predisposition to infection, which may even occur in patients who are still asymptomatic.

Objective To determine and to analyze the theoretical and practical knowledge of Nursing professionals on indirect blood pressure measurement.Methods This cross-sectional study included 31 professionals of a coronary care unit (86% of the Nursing staff in the unit). Of these, 38.7% of professionals were nurses and 61.3% nurse technicians. A validated questionnaire was used to theoretical evaluation and for practice assessment the auscultatory technique was applied in a simulation environment, under a non-participant observation.Results To the theoretical knowledge of the stages of preparation of patient and environment, 12.9% mentioned 5-minute of rest, 48.4% checked calibration, and 29.0% chose adequate cuff width. A total of 64.5% of professionals avoided rounding values, and 22.6% mentioned the 6-month deadline period for the equipment calibration. On average, in practice assessment, 65% of the steps were followed. Lacks in knowledge were primary concerning lack of checking the device calibration and stethoscope, measurement of arm circumference to choose the cuff size, and the record of arm used in blood pressure measurement.Conclusion Knowledge was poor and had disparities between theory and practice with evidence of steps taken without proper awareness and lack of consideration of important knowledge during implementation of blood pressure measurement. Educational and operational interventions should be applied systematically with institutional involvement to ensure safe care with reliable values.

Estudo com o objetivo identificar o conhecimento de alunos em Enfermagem de uma universidade pública do interior paulista sobre segurança do paciente. Trata-se de estudo quantitativo, transversal, entre maio e junho de 2011. Participaram 118 alunos regularmente matriculados no terceiro, quarto e quinto anos. Questionário autoaplicável foi analisado com estatística descritiva. Os resultados apontam que parte dos alunos considera que a assistência de enfermagem é insegura e pode trazer riscos. A falta de preparo da equipe é considerada como fator dificultador para que se preste assistência segura. Além disso, grande parte dos alunos desconhece o termo evento adverso. Conclui-se que os alunos conseguem contemplar os aspectos relacionados à segurança do paciente e as responsabilidades do enfermeiro para alcance de assistência segura. Porém, é necessário ampliar o escopo do ensino sobre esta temática.

Refeeding syndrome (RFS) has been well described but is also a frequently forgotten and undiagnosed complication in clinical practice, which, if untreated, may lead to death. Patients who are more prone to developing RFS are those with at least one of the following conditions: BMI <16 kg/m(2), a recent unintentional weight loss >15%, very little nutritional intake for >10 days, and/or low plasma concentrations of potassium, phosphate or magnesium before feeding; and those with at least two of the following conditions: BMI <18.5 kg/m(2), a recent weight loss >10%, very little nutritional intake for >5 day, and/or a history of alcohol abuse or drug use, including insulin, chemotherapy or diuretics. We report here a patient who, after undergoing intestinal resection (short gut syndrome), presented diarrhoea, weight loss and protein-energy malnutrition. After nutritional assessment, the nutritional support team decided to feed the patient by the parenteral route. After 16 h of parenteral nutrition, the patient developed supraventricular tachycardia, hypomagnesaemia and hypocalcaemia, and RFS was diagnosed and managed. After intestinal adaptation, the patient is currently able to maintain his nutritional status with nutrition therapy by the oral route.

The aim of the present study was to report the occurrence of serious subnutrition, associated to intestinal bacterial overgrowth, in two patients submitted to bariatric surgery. Two female patients (body mass index, 49 and 50 kg/m(2), respectively) were submitted to Y-en-Roux gastric bypass. The first patient evolved a 52% loss of body weight within 21 months after surgery; the other, a 34% loss of initial body weight within 15 months after surgery, results corresponding, respectively, to 62 and 45 kg weight losses. However, both patients reported asthenia, hair fallout, and edema, and one also reported diarrhea, but none was feverish. Their respective albuminemias were of 24 and 23 g/l. A respiratory hydrogen test suggested bacterial hyperproliferation. Thirty days after ciprofloxacin and tetracyclin treatments, they showed improved albumin levels and nutritional states, both confirmed by results of hydrogen breath tests. Bacterial overgrowth is an important complication that can compromise clinical evolution of patients submitted to intestinal surgery like gastroplasty with Y-Roux anastomosis. In cases of clinical suspicion or a confirmed diagnosis, adequate antibiotics, sometimes requiring to be cyclically repeated, should be administered.

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Introdução: A medida da pressão arterial é parte do exame físico realizado por estudantes da área da saúde. Metodologias ativas podem estar vinculadas ao sistema de ensino, com contribuições positivas para o conhecimento sobre as etapas da medida da PA. Objetivo: Comparar o conhecimento sobre as etapas da medida da PA, pré e pós uma intervenção educativa entre estudantes de fisioterapia e medicina. Método: Estudo quase experimental, com grupo único que será controle dele mesmo, antes e depois da intervenção, realizado no ano de 2020, na Unifran. As avaliações foram baseadas nas metodologias ativas: KAHOOT, para avaliação teórica, e o método OSCE para avalição prática. Realizou-se uma intervenção educativa, com o recurso da Sala de Aula Invertida, seguida de debates, utilizando a prática e simulação para melhor aprendizado. Utilizou-se o teste de Wilcoxon, na comparação pré e pós intervenção, sobre o conhecimento teórico e prático dos estudantes referentes à medida da PA. Resuladots: 81 estudantes, idade média de 22,31+3,24 anos. No conhecimento teórico, a partir do KAHOOT, na comparação pré e pós intervenção educativa, observou-se diferença significativa no total dos itens de acertos (p<0,001), exceto na etapa “posição do paciente” (p=0,227). Na análise do conhecimento prático, a partir do checklist utilizado no OSCE, houve melhora significativa após a intervenção educativa em todas as etapas analisadas (p=0,001). Conclusão: a intervenção educativa com metodologias ativas Sala de aula invertida, KAHOOT e OSCE foram efetivas na apreensão de conhecimento sobre a medida da PA e sugere estudos de maior amplitude.