RESUMO
BACKGROUND: Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. OBJECTIVE: To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. METHOD: We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used. RESULTS: A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. CONCLUSION: The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.
Assuntos
Near Miss , Gestão de Riscos , Brasil , Criança , Hospitais , Humanos , Recém-Nascido , Estudos RetrospectivosRESUMO
BACKGROUND: Reporting falls in the hospital setting is a world-recognized strategy to prevent these incidents. OBJECTIVE: To describe in-hospital falls reported in a large hospital in the South of Brazil. METHOD: Retrospective, descriptive study of falls reported in the hospital's electronic reporting system. RESULTS: We analyzed 1071 fall incidents. The incidence of falls in inpatient units was 1.7 per 1000 patient days. Among the recorded falls, 95.3% occurred in patients who had been previously assessed as being at high or moderate risk of falls; 61.5% were using medications associated with increased risk of falls. Regarding age, 70.8% of the falls occurred in patients aged ≥60â¯years. Falls occurred mostly (72.6%) in inpatients units, and in 63.4% of the incidents the fall was witnessed by a family member/companion or a health team professionals. No injuries were recorded in 71.4% of the patients. Serious adverse events or sentinel events, such as fractures or head trauma occurred in 2.1% of the patients. Of these, 80% were in the group aged ≥60â¯years; 83% of the head traumas and 58% of the fractures occurred in patients who had been assessed as being at high risk of falls. Fractures were associated (pâ¯=â¯0.026) with age 70-79â¯years. CONCLUSION: At the hospital where the study was performed, new fall prevention strategies must focus on patients admitted to inpatient units, aged ≥60â¯years, assessed as being at high risk of falls, and using medications associated with increased risk of falls.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Hospitais Públicos , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVES: The present database contains information on patient falls in the hospital setting. Data were collected in January 2018 with of describing in-hospital falls reported from 1st January 2012 to 31 December 2017 in a large hospital in the South of Brazil. Learning about the characteristics of these events and establishing a profile may contribute to the design of adequate prevention and improvement strategies that are effective to reduce the risk of falls. DATA DESCRIPTION: This data set encompasses 1.071 in-patients falls characterized by the follow variables: year, date, patient birth, weekday, shift, department/location of the incident, location, severity, presence of companion, age, sex, risk level, medication associated with fall risk, implemented fall prevention protocol, type of injury, reason, restraint prescription, physical therapy prescription.