Ocorrência de eventos adversos em unidade de hemodinâmica

Abstract

Objective: to analyze the adverse events occurred with patients during procedures performed at a hemodynamic unit. Method: this is a quantitative, documentary, retrospective and cross-sectional cohort study through the analysis of the records in the books of nursing notes. Data were analyzed in SPSS and descriptive statistical analysis was performed and presented in the form of tables. Results: there were 84 adverse events related to medical devices or equipment and clinical procedures or processes. The main causes are lack of material resources and failure in the service settings. The consequences identified were delay of diagnosis and treatment and the worsening of the clinical situation, which were not notified. Conclusion: the study showed that the occurrence of adverse events is multifactorial and reveals the importance of improving the management regarding the physical structure and materials. Furthermore, adverse events are considered an important indicator of the quality of assistance, since they allow an organizational diagnosis and changes in the structure and work processes to achieve a culture of institutional safety. Descriptors: Patient Harm; Hemodynamics; Patient Safety; Nursing; Patient-Centered Care; Quality of Health Care.RESUMO Objetivo: analisar os eventos adversos ocorridos com pacientes durante procedimentos efetuados em uma unidade de hemodinâmica. Método: trata-se de estudo quantitativo, documental, retrospectivo e de coorte transversal realizado por meio da análise dos registros nos livros de anotações de enfermagem. Estudaram-se os dados no SPSS e realizou-se a análise estatística descritiva apresentando em forma de tabelas. Resultados: identificaram-se 84 eventos adversos relacionados aos dispositivos ou equipamentos médicos e aos procedimentos ou processos clínicos. Verificou-se que as principais causas consistem na falta de recursos materiais e na falha na estrutura do serviço. Identificaram-se, como consequências, o atraso do diagnóstico e do tratamento e o agravamento da situação clínica. Destaca-se que esses agravos não foram notificados. Conclusão: verifica-se que a ocorrência dos eventos adversos é multifatorial e revela a importância da melhoria da gestão quanto à estrutura física e de materiais. Consideram-se, além disso, os eventos adversos como um importante indicador da qualidade da assistência, pois permitem um diagnóstico organizacional e as mudanças na estrutura e processos de trabalho para o alcance de uma cultura de segurança institucional. Descritores: Dano ao Paciente; Hemodinâmica; Segurança do Paciente; Enfermagem; Assistência Centrada no Paciente; Qualidade da Assistência à Saúde.RESUMENObjetivo: analizar los eventos adversos ocurridos con pacientes durante procedimientos realizados en una unidad de hemodinamia. Método: se trata de un estudio cuantitativo, documental, de cohorte retrospectivo y de corte transversal a través del análisis de los registros en los libros de notas de enfermería. Los datos fueron analizados en SPSS y el análisis estadístico descriptivo se presenta en forma de tablas. Resultados: se identificaron 84 eventos adversos relacionados con dispositivos médicos o equipos y procedimientos o procesos clínicos. Se encontró que las principales causas son la falta de recursos materiales y el fracaso en la estrutura del servicio. Se identificaron como consecuencias, el retraso del diagnóstico y tratamiento y el empeoramiento de la situación clínica, las cuales no fueron notificadas. Conclusión: parece que la ocurrencia de eventos adversos es multifactorial y revela la importancia de la mejora de la gestión en cuanto a la estructura física y material. Se consideran, además, eventos adversos como un indicador importante de la calidad de la asistencia, ya que permiten un diagnóstico organizacional y los cambios en la estructura y los procesos de trabajo, para lograr una cultura de seguridad institucional. Descriptores: Daño del Paciente; Hemodinámica; Seguridad del Paciente; Enfermería; Atención Dirigida al Paciente; Calidad de la Atención de Salud.

Eventos adversos a meios de contraste iodados em angioplastias coronárias

“…[14][15] In the same studies, it has been shown that there is no evidence that female is a major predictor of adverse events, complementing the hypothesis of this study, that sex should not be considered a risk factor, since only 1/3 of the events occurred in female subjects. [14][15] It has been shown in a similar study that the adverse event related to excessive exposure to contrast can increase the length of hospital stay, create the need for additional procedures and also cause irreversible consequences for the patient, such as the incidence of 10 to 30 % of contrastinduced nephropathy (CIN). [21][22] In addition, patients should be hydrated before and after administration of ICMs, according to creatinine clearence.…”

“…In studies conducted in hemodynamic units and in a teaching hospital in Goiânia, it was demonstrated that the prevalence of adverse events was low when compared to the high demand and turnover of patients in those units. [13][14][15][16] It is understood that it is well known that ICM doses should be tailored to the examination and regions to be tested, as well as body weight and renal function of the individual, especially in children. [17][18][19] In a study of immediate complications related to cardiac catheterization, it has been shown that these may be local or systemic, with vascular, vasovagal, ischemic and allergic complications being more frequent.…”

“…Thus, it is essential the training of the Nursing team and medical team to deal with this type of situation, performing Nursing history and medical consultation with emphasis on the identification of risk factors for the occurrence of adverse events. [14][15] It has been shown in other studies that the previous history of adverse reaction to iodinated contrast is the main risk factor for the development of a new reaction, and also that if the previous reaction is to non-ionic contrast, the individual has a risk five times greater to develop a new reaction, compared to those who never received this contrast or who received it and had no reaction. 11,[14][15] In this way, the patient's history must be investigated before the beginning of any procedure, as well as the development of continuous and systematic evaluation of the necessary resources, such as the risk management of patients most susceptible before, during and after the procedures.…”

“…[14][15] It has been shown in other studies that the previous history of adverse reaction to iodinated contrast is the main risk factor for the development of a new reaction, and also that if the previous reaction is to non-ionic contrast, the individual has a risk five times greater to develop a new reaction, compared to those who never received this contrast or who received it and had no reaction. 11,[14][15] In this way, the patient's history must be investigated before the beginning of any procedure, as well as the development of continuous and systematic evaluation of the necessary resources, such as the risk management of patients most susceptible before, during and after the procedures. [14][15] In the same studies, it has been shown that there is no evidence that female is a major predictor of adverse events, complementing the hypothesis of this study, that sex should not be considered a risk factor, since only 1/3 of the events occurred in female subjects.…”

“…11,[14][15] In this way, the patient's history must be investigated before the beginning of any procedure, as well as the development of continuous and systematic evaluation of the necessary resources, such as the risk management of patients most susceptible before, during and after the procedures. [14][15] In the same studies, it has been shown that there is no evidence that female is a major predictor of adverse events, complementing the hypothesis of this study, that sex should not be considered a risk factor, since only 1/3 of the events occurred in female subjects. [14][15] It has been shown in a similar study that the adverse event related to excessive exposure to contrast can increase the length of hospital stay, create the need for additional procedures and also cause irreversible consequences for the patient, such as the incidence of 10 to 30 % of contrastinduced nephropathy (CIN).…”