CUIDADOS DE ENFERMAGEM E EVENTOS ADVERSOS EM DOENTES INTERNADOS: ANÁLISE DOS FATORES INTERVENIENTES
NURSING CARE AND ADVERSE EVENTS AT INPATIENTS IN ACUTE HOSPITALS: THE ROOT CAUSE ANALYSIS
Purpose: Aims to characterize the main adverse events associated with the practice of nursing, in hospitalized patients and understand how different circumstantial facts interact in its occurrence. Methods: This is a qualitative study using semi-structured interviews. Were interviewed 18 nurses, working in the hospital unit. The reports were analyzed following the adverse event analysis model(1). Results: Reports show a wide variability of error types, emphasizing medication errors, falls, errors of omission and commission in performing nursing practices, such as gaps in surveillance, clinical judgment, respect for privacy and advocating the patient’ interests. We identified the chain of human and systemic factors that intervened in the route events. The results warned the possible association between the occurrence of adverse events, less suitable nursing practices and unfavorable work environments. Conclusions: The results support the need for more leadership commitment to safety, improvement of human and material resources, coordination and communication between different professionals and services, training of professionals on risk management and patient safety, as well as greater development of safety culture.
Keywords: Patient safety; nursing; risk; leadership.
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