Learning from mistakes: analyzing incidents in a neonatal care unit

Abstract

Objective:to analyze incidents reported in a neonatal care unit. Method:a quantitative, cross-sectional and retrospective study with a sample of 34 newborns. Data were collected through a structured form, composed of two parts: sociodemographic/clinical characteristics of the newborns, and characteristics of the reported incidents. Data were collected from the institution’s computer system, in a period corresponding to 13 months, and analyzed by means of descriptive statistics. Results:the majority of the newborns were preterm (70.6%), male (52.9%) and born through caesarean section (76.5%). During the study period, 54 incidents were reported, totaling a frequency of 1.6 incident per newborn. It was found that 61.1% of incidents were related to medicines, 14.8% to accidental loss of tracheal tube and 9.3% to catheter obstruction. Conclusion:analysis of the reported incidents has shown that most incidents refer to the drug process. Information about the incidents can increase the perception of health professionals regarding the impact of their actions.

<p>Translation, Cross-Cultural Adaptation, and Measurement Properties of the Portuguese Version of the Global Trigger Tool for Adverse Events</p>

“…For example, some researchers state that about 10-12.5% of the hospitalized patients are victims of AE [6][7][8] resulting from healthcare provision, 10 and others identified AE rates of 20.5-44.6%. [10][11][12][13] The most frequent types of AE reported were surgical injuries, medication errors, healthcare-related infections, and allergic reactions. 2,8 These important differences in AE prevalence are probably due to the different methods and designs used.…”

“…These methods can be fundamental instruments in PS if these incidents and AE are communicated and analyzed. 13 However, the literature shows that most incidents are not reported by health professionals, 14 with underreporting 15 since only 10-20% of the AEs are reported. [16][17][18] Likewise, the codification of clinical processes is affected by the quality of the records made by health professionals, 17,18 and thus the analysis of AEs becomes insufficient.…”

“…Therefore, health institutions must know the reality to provide high-quality care, learning from their mistakes and implementing valid, sensitive, cost-effective, and easy-touse instruments and protocols 2,13,19 that can provide useful and reliable real-time data. 12,14,20,21 The Institute for Healthcare Improvement (IHI) developed the Global Trigger Tool (GTT-IHI), 22 which showed international promise in identifying and quantifying patient harm severity, consequently decreasing the occurrence of AE.…”

“…Therefore, health institutions must know the reality to provide high-quality care, learning from their mistakes and implementing valid, sensitive, cost-effective, and easy-to-use instruments and protocols 2 , 13 , 19 that can provide useful and reliable real-time data. 12 , 14 , 20 , 21 …”

Os pais como pilares para a segurança do paciente em unidade neonatal

“…Em relação ao erro de infusão de medicação percebido pelos pais, destaca-se que os eventos adversos relacionados ao processo de medicação estão entre os incidentes mais comuns nas unidades de cuidados neonatais 13,14 . Em estudo realizado na Alemanha, foram observadas 281 preparações de medicamentos em UTINs, encontrando-se 38 erros, sendo os mais comuns a falta de uniformização na reconstituição/diluição dos medicamentos e a velocidade incorreta da infusão das soluções 15 .…”