Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS)

Introduction: Quality and safety is an important challenge in healthcare systems all over the world particularly in developing parts. Objective: This survey aimed to assess patient safety culture (PSC) in emergency departments (EDs) in Yemen and identify its associated factors. Methods: A questionnaire containing the Hospital Survey on Patient Safety Culture (HSOPSC) was distributed to ED physicians, nurses, and clinical, and non-clinical staff at three public teaching general hospitals. The percentages of positive responses on the 12 patient safety dimensions and the summation of PSC and two outcomes (overall patient safety grade and adverse events reported in the past year) were assessed. Factors associated with PSC aggregate score were analyzed. Results: finally, out of 400 questionnaires, 250 (64%) were analyzed. In total, 207 (82.3%) participants were nurses and physicians; 140 (56.0%) were male; 134 (53.6%) were less than 30 years old; and 134 (53.6%) had a university degree. Participants provided the highest ratings for the “teamwork within units” PSC composite (67%). The lowest rating was for “non-punitive response to error” (21.3%). A total of 120 (48.1%) participants did not report any events in the past year and 99 (39.7%) gave their hospital an “excellent/very good” overall patient safety grade. There were signiﬁcant differences between the hospitals’ EDs in the rating of “handoffs and transitions” (p=0.016), “teamwork within units” (p=0.018), and “frequency of adverse events reported” (p=0.016). Staff working in intensive care units (8.4%, n=21) had lower patient safety aggregate scores. Conclusions: PSC ratings appear to be low in Yemen. This study emphasizes the need to create and maintain a PSC in EDs through the implementation of quality improvement strategies and environment of transparency, open communications, and continuous learning.

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Factors associated with mechanical and systemic adverse events after colonoscopy (France, 2010-2015)

European Journal of Public Health ◽

10.1093/eurpub/ckz186.606 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

M Laanani ◽

A Weill ◽

P O Blotière ◽

J Pouchot ◽

F Carbonnel ◽

...

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Adverse Events ◽

Older Patients ◽

Public Hospitals ◽

Serious Adverse Events ◽

Logistic Regression Models ◽

Factors Associated ◽

Increased Risk ◽

Experienced Endoscopists

Abstract Background More than one million colonoscopies are performed every year in France. They are associated with risks of mechanical and systemic serious adverse events (SAEs) which can be associated with patient, procedure, endoscopist, and facility characteristics. We tried to identify the factors associated with colonic perforation, gastrointestinal bleeding, splenic injury, shock, myocardial infarction, stroke, pulmonary embolism, acute renal failure, and urolithiasis after colonoscopy. Methods We analysed data from the French national claims databases (SNDS). A total of 4,088,799 patients, 30 years or older, undergoing a first screening or diagnostic colonoscopy between 2010 and 2015 were identified. SAE rates were estimated, and risk factors associated with SAEs were identified using multilevel logistic regression models, adjusted for patient, colonoscopy, endoscopist, and facility characteristics. Results Increasing age was associated with an increasing incidence of mechanical and systemic SAEs. Cancer and cardiovascular comorbidities were associated with mechanical SAEs, and a higher number of pre-existing conditions was associated with shock and acute renal failure. Polypectomy, especially of polyps larger than 1 cm, was associated with an increased risk of perforation (OR = 4.1; 95% CI, 3.4-5.0) and bleeding (OR = 13.3; 95% CI, 11.7-15.1). Mechanical SAEs were associated with the endoscopist’s experience, while systemic SAEs were more frequent in public hospitals than in private clinics. Conclusions SAEs related to colonoscopy were more frequent in older patients and in those with comorbidities. Mechanical SAEs were more frequent when colonoscopy was performed by less experienced endoscopists. Systemic SAEs were more frequent in public hospitals, reflecting patient selection processes. The risk of both mechanical and systemic SAEs should be taken into account when deciding to perform colonoscopy, particularly in older patients with multiple pre-existing conditions. Key messages Systemic SAEs are not uncommon after colonoscopy and, together with intestinal SAEs, should be considered when considering the need for colonoscopy. Patients at risk of SAEs should be identified and colonoscopy should be performed by experienced endoscopists in these patients. Less invasive alternatives should also be considered in these patients.

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How do rural GPs’ workloads and work activities differ with community size compared with metropolitan practice?

Australian Journal of Primary Health ◽

10.1071/py11063 ◽

2012 ◽

Vol 18 (3) ◽

pp. 228 ◽

Cited By ~ 23

Author(s):

Matthew R. McGrail ◽

John S. Humphreys ◽

Catherine M. Joyce ◽

Anthony Scott ◽

Guyonne Kalb

Keyword(s):

Rural Communities ◽

Public Hospitals ◽

National Study ◽

Work Demands ◽

Medical Workforce ◽

Community Size ◽

Hours Worked ◽

Small Communities ◽

Work Activities ◽

After Hours

Rural communities continue to experience shortages of doctors, placing increased work demands on the existing rural medical workforce. This paper investigates patterns of geographical variation in the workload and work activities of GPs by community size. Our data comes from wave 1 of the Medicine in Australia: Balancing Employment and Life longitudinal study, a national study of Australian doctors. Self-reported hours worked per usual week across eight workplace settings and on-call/ after-hours workload per usual week were analysed against seven community size categories. Our results showed that a GP’s total hours worked per week consistently increases as community size decreases, ranging from 38.6 up to 45.6 h in small communities, with most differences attributable to work activities of rural GPs in public hospitals. Higher on-call workload is also significantly associated with smaller rural communities, with the likelihood of GPs attending more than one callout per week ranging from 9% for metropolitan GPs up to 48–58% in small rural communities. Our study is the first to separate hours worked into different work activities whilst adjusting for community size and demographics, providing significantly greater insight to the increased hours worked, more diverse activities and significant after-hours demands experienced by current rural GPs.

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Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a m ulticenter, placebo controlled, double blind, randomized clinical trial

10.21203/rs.2.22208/v3 ◽

2020 ◽

Author(s):

Carlos Torrecilla ◽

Jaime Fernández-Concha ◽

José R. Cansino ◽

Juan A. Mainez ◽

José H. Amón ◽

...

Keyword(s):

Placebo Group ◽

Adverse Events ◽

Controlled Trial ◽

Intervention Group ◽

Ph Control ◽

Public Hospitals ◽

Urine Ph ◽

Double Blind ◽

Double J Stent ◽

Oral Composition

Abstract Background: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks.Participants, design and intervention: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. Outcome measurements and statistical analysis: The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 – none; 3 – global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events.Results: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the intervention group and 18.91 (102.27) in the placebo group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups.Conclusions: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation.Trial registration: This trial was registered at www.clinicaltrials.gov under the name “Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent” with date 2nd November 2017, code NCT03343275, and URL:https://clinicaltrials.gov/ct2/show/record/NCT03343275?term=NCT03343275&draw=2&rank=1

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Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a m ulticenter, placebo controlled, double blind, randomized clinical trial

10.21203/rs.2.22208/v5 ◽

2020 ◽

Author(s):

Carlos Torrecilla ◽

Jaime Fernández-Concha ◽

José R. Cansino ◽

Juan A. Mainez ◽

José H. Amón ◽

...

Keyword(s):

Placebo Group ◽

Adverse Events ◽

Controlled Trial ◽

Intervention Group ◽

Ph Control ◽

Public Hospitals ◽

Urine Ph ◽

Double Blind ◽

Double J Stent ◽

Oral Composition

Abstract Background: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks.Methods: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 – none; 3 – global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events.Results: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the placebo group and 18.91 (102.27) in the intervention group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups. Conclusions: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation.Trial registration: This trial was registered at www.clinicaltrials.gov under the name “Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent” with date 2nd November 2017, code NCT03343275, and URL:https://clinicaltrials.gov/ct2/show/record/NCT03343275?term=NCT03343275&draw=2&rank=1

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Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a m ulticenter, placebo controlled, double blind, randomized clinical trial

10.21203/rs.2.22208/v4 ◽

2020 ◽

Author(s):

Carlos Torrecilla ◽

Jaime Fernández-Concha ◽

José R. Cansino ◽

Juan A. Mainez ◽

José H. Amón ◽

...

Keyword(s):

Placebo Group ◽

Adverse Events ◽

Controlled Trial ◽

Intervention Group ◽

Ph Control ◽

Public Hospitals ◽

Urine Ph ◽

Double Blind ◽

Double J Stent ◽

Oral Composition

Abstract Background: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks. Methods: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 – none; 3 – global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events. Results: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the placebo group and 18.91 (102.27) in the intervention group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups. Conclusions: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation. Trial registration: This trial was registered at www.clinicaltrials.gov under the name “Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent” with date 2nd November 2017, code NCT03343275, and URL: https://clinicaltrials.gov/ct2/show/record/NCT03343275?term=NCT03343275&draw=2&rank=1 Keywords: double J stent; encrustation; nutraceutical; L-methionine; phytin; pH.

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Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study

BMJ Open ◽

10.1136/bmjopen-2019-035238 ◽

2020 ◽

Vol 10 (10) ◽

pp. e035238

Author(s):

Fátima Jiménez-Pericás ◽

María Teresa Gea Velázquez de Castro ◽

María Pastor-Valero ◽

Carlos Aibar Remón ◽

Juan José Miralles ◽

...

Keyword(s):

Cohort Study ◽

Adverse Events ◽

Primary Outcome ◽

Incidence Rates ◽

University Hospital ◽

Incidence Density ◽

Secondary Outcome ◽

National Study ◽

Exclusion Criteria ◽

Healthcare Associated

ObjectiveTo determine whether isolated patients admitted to hospital have a higher incidence of adverse events (AEs), to identify their nature, impact and preventability.DesignProspective cohort study with isolated and non-isolated patients.SettingOne public university hospital in the Valencian Community (southeast Spain).ParticipantsWe consecutively collected 400 patients, 200 isolated and 200 non-isolated, age ≥18 years old, to match according to date of entry, admission department, sex, age (±5 years) and disease severity from April 2017 to October 2018. Exclusion criteria: patients age <18 years old and/or reverse isolation patients.Primary and secondary outcome measuresThe primary outcome as the AE, defined according to the National Study of Adverse Effects linked to Hospitalisation (Estudio Nacional Sobre los Efectos Adversos) criteria. Cumulative incidence rates and AE incidence density rates were calculated.ResultsThe incidence of isolated patients with AEs 16.5% (95% CI 11.4% to 21.6%) compared with 9.5% (95% CI 5.4% to 13.6%) in non-isolated (p<0.03). The incidence density of patients with AEs among isolated patients was 11.8 per 1000 days/patient (95% CI 7.8 to 15.9) compared with 4.3 per 1000 days/patient (95% CI 2.4 to 6.3) among non-isolated patients (p<0.001). The incidence of AEs among isolated patients was 18.5% compared with 11% for non-isolated patients (p<0.09). Among the 37 AEs detected in 33 isolated patients, and the 22 AEs detected in 19 non-isolated patients, most corresponded to healthcare-associated infections (HAIs) for both isolated and non-isolated patients (48.6% vs 45.4%). There were significant differences with respect to the preventability of AEs, (67.6% among isolated patients compared with 52.6% among non-isolated patients).ConclusionsAEs were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAIs as the primary cause. It is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.

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Efficacy and Safety of Imatinib on Top of BFM-Like Chemotherapy in Pediatric Patients with Ph+/BCR-ABL+ Acute Lymphoblastic Leukemia (Ph+ALL). the EsPhALL Study

Blood ◽

10.1182/blood.v118.21.873.873 ◽

2011 ◽

Vol 118 (21) ◽

pp. 873-873 ◽

Cited By ~ 3

Author(s):

Andrea Biondi ◽

Martin Schrappe ◽

Paola Di Lorenzo ◽

Anders Castor ◽

Giovanna Lucchini ◽

...

Keyword(s):

Bone Marrow ◽

Complete Remission ◽

Adverse Events ◽

Lymphoblastic Leukemia ◽

Philadelphia Chromosome ◽

Early Response ◽

National Study ◽

Induction Phase ◽

Free Survival ◽

Significant Difference

Abstract Abstract 873 Background. Philadelphia chromosome positive (Ph+) ALL accounts for 3–5% of pediatric ALL. An international survey on 640 children diagnosed between 1995 and 2005 and treated with chemotherapy and stem cell transplantation (SCT) without the use of tyrosin kinase inhibitors (TKI) recently reported an overall 7-year event free survival (EFS) and overall survival (OS) of 31.2% and 44.2%, respectively. In those years, only limited experience was accumulated on the use of Imatinib (IM) for children with Ph+ leukemia. The EsPhALL study was designed as an intergroup, open-label, randomized Phase II/III study, within the I-BFM-SG network, to assess the safety and efficacy of IM in association with chemotherapy. Ten national study groups participated in the study: AIEOP, BFM-G/CH, COALL, FRALLE, NOPHO, MRC, DCOG, CPH, PINDA and HONG KONG. Methods. Patients 1 to 18 years of age diagnosed with Ph+ ALL were eligible to the study. After the induction phase according to national treatment protocol, patients were classified as Good Risk (GR) or Poor Risk (PR) according to their response to treatment. GR patients were those who achieved both the early response (i.e. blast cell count <1000/ml in peripheral blood after 7 days of prednisone and a single dose of intrathecal methotrexate or M1/M2 bone marrow at day 15 or M1 at day 21) and the complete remission after the frontline Induction course (1st complete remission, CR1). They were randomized to receive IM in combination with chemotherapy (GR-IM) or chemotherapy alone (GR-noIM). PR patients (those who did not achieved early response or CR1 or both) received IM in combination with chemotherapy. Due to the availability of external evidence, the randomization in GR was stopped in 2009 and an amended trial started, with all patients receiving IM continuously. The chemotherapy regimen was modeled upon a BFM high risk backbone and IM was delivered at the dose of 300 mg/m2/day. SCT in CR1 was recommended for all PR patients (any donor) and for GR patients if a genotype-matched donor (9/10 or 10/10 alleles) was available. The primary analysis for the randomized question (ITT) was on disease-free survival (DFS) in GR and EFS in PR patients, not censoring for SCT in CR1, with comparison based on the log-rank test. Results. Between 01-Jan-2004 and 31-Dec-2009, 178 patients (age 1.5–17.9 years) were enrolled and stratified as GR (108; 61%) or PR (70; 39%). Ninety GR patients were randomized (18 excluded for parental refusal or clinical decision); of these, 77% underwent SCT in CR1. Out of 35 PR patients who were resistant to Induction, 80% achieved CR1 after consolidation (Phase IB). 84% of PR patients received SCT in CR1. Relapse was the first event in 23 (33%), 12 (27%) and 10 (22%) of PR, GR-noIM and GR-IM patients, respectively. The most common site was the bone marrow (74%, 92% and 60% in PR, GR-noIM and GR-IM patients, respectively). Deaths in CR1 were 8, 4 and 2 in PR, GR-noIM and GR-IM patients respectively, none being related to IM. The 4-year DFS was 73% (95% CI: 56% – 84%) in the GR-IM arm and 62% (95% CI: 45% – 75%) in the GR-noIM arm (p=0.24), with a 4-year OS of 85% (95% CI: 70% – 93%) and 73% (95% CI: 54% – 85%), respectively (p= 0.37). A secondary ‘as treated' analysis was performed accounting for 13 patients who switched from GR-noIM to GR-IM, with 4-year DFS of 56% (95% CI: 36% – 72%) and 75% (95% CI: 61% – 85%), respectively (p=0.06). The EFS in PR patients was 54% (95% CI: 40% – 65%) at 2-years and remained constant through 3 and 4 years, with a 4-year OS of 64% (95% CI: 50% – 74%).The most frequently reported adverse events (AEs) across the treatment arms were decreased leukocytes, platelets and granulocyte counts, decreased hemoglobin, and infections. There was no significant difference in the overall frequency of AEs across all 3 patients' groups. Severe adverse events rate was 28% in GR-IM group, 32% in GR-noIM and 34% in PR group. Conclusions. Results suggest that the addition of IM to intensive BFM-type chemotherapy regimens was associated with an approximate 10% advantage in long-term DFS in GR patients which, however, the study was not powered to detect. The PR group treated with IM had improved EFS and OS as compared to historical controls. IM was generally well tolerated on top of intensive chemotherapy with a reassuring safety profile. Disclosures: Biondi: BMS, Novartis, Micromed: Consultancy, Membership on an entity's Board of Directors or advisory committees.

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Occurrence of adverse events in public hemodialysis units

Enfermería Global ◽

10.6018/eglobal.18.3.343361 ◽

2019 ◽

Vol 18 (3) ◽

pp. 1-34

Author(s):

Renata de Paula Faria Rocha ◽

Diana Lúcia Moura Pinho

Keyword(s):

Adverse Events ◽

Renal Disease ◽

Vascular Access ◽

Chronic Renal Disease ◽

Federal District ◽

Public Hospitals ◽

Calidad De Vida ◽

Complex Procedure ◽

La Red

Objetivo: Identificar lo eventos adversos que ocurren en unidades de hemodiálisis de la red pública del Distrito Federal. Métodos: Se trata de un estudio descriptivo con enfoque cuantitativo, realizado en Brasilia/DF. Los datos se recopilaron en tres hospitales públicos de la Secretaría de Salud del DF en el año 2017. Esas unidades, en conjunto, realizaron en el año 2017, 1770 sesiones de hemodiálisis en pacientes con Insuficiencia Renal Crónica por mes. Se analizaron 152 historiales de pacientes para el levantamiento de los registros. Los datos fueron organizados en hoja de Excel, y se utilizó la estadística descriptiva para el análisis. Resultados: Los acontecimientos adversos con mayor número de registros están relacionados con el acceso vascular para hemodiálisis, son: sangramiento, secreción en catéter doble lumen, flujo sanguíneo inadecuado e infección o señales de infección en el acceso vascular. Respecto al responsable del registro, 76,9%de los registros fueron realizados por los técnicos en enfermería, 16,6% por los enfermeros y 6,5% por otros profesionales del equipo de salud. Conclusión: La hemodiálisis es un sector con un gran potencial de riesgo para la ocurrencia de eventos adversos, esto sucede por diversos motivos tales como, tratarse de un procedimiento complejo, con uso de alta tecnología, la característica de cronicidad de la enfermedad renal crónica, el uso alto de medicamentos. Deben adoptarse estrategias para mejorar el funcionamiento de estos accesos vasculares, pues de ellos depende la calidad de la diálisis y consecuentemente la calidad de vida del paciente con enfermedad renal crónica en tratamiento dialítico. Objective: Identify the adverse events occurring in hemodialysis units of the Federal District public network.Methods: This is a descriptive study with a quantitative approach, carried out in Brasília / DF. Data were collected in three public hospitals of the Health's Secretary of the Federal District in the year 2017. These units, together, performed in the year 2017, 1770 hemodialysis sessions in patients with CKD per month. A total of 152 patient charts were analyzed to record adverse events. The data were organized in an Excel spreadsheet, and descriptive statistics were used for the analysis. Results: Adverse events with the highest number of records are related to vascular access to hemodialysis, they are: bleeding, double-catheter secretion lumen, inadequate blood flow, and infection or signs of vascular access infection. As for the person responsible for the registration, 76.9% of the records were made by nursing technicians, 16.6% by nurses and 6.5% by other health team professionals.Conclusion: It is concluded in this study that hemodialysis is a hospital sector with a great risk potential for the occurrence of adverse events, this occurs for several reasons such as: it is a complex procedure, using high technology, chronicity characteristic of chronic renal disease, the high use of medications. Strategies need to be taken in order to optimize the functioning of these vascular accesses, because the quality of dialysis depends on them, consequently the quality of life of the patient with chronic renal disease in dialysis treatment. Objetivo: Identificar os eventos adversos que ocorrem em unidades de hemodiálise da rede pública do Distrito Federal.Métodos: Trata-se de um estudo descritivo com abordagem quantitativa, realizado em Brasília/DF. Os dados foram coletados em três hospitais públicos da Secretaria de Saúde do DF no ano de 2017. Essas unidades, em conjunto, realizaram no ano de 2017, 1770 sessões de hemodiálise em pacientes com DRC por mês. Foram analisados 152 prontuários de pacientes para levantamento dos registros de eventos adversos. Os dados foram organizados em planilha do Excel, e utilizado estatística descritiva para a análise.Resultados: Os eventos adversos com maior número de registros estão relacionados ao acesso vascular para hemodiálise, são eles: sangramento, secreção em cateter duplo lumen, fluxo sanguíneo inadequado e infecção ou sinais de infecção no acesso vascular. Quanto ao responsável pelo registro, 76,9% dos registros foram realizados pelos técnicos de enfermagem, 16,6% pelos enfermeiros e 6,5% por outros profissionais da equipe de saúde.Conclusão: Conclui-se com este estudo que a hemodiálise é um setor hospitalar com um grande potencial de risco para a ocorrência de eventos adversos, isso ocorre por diversos motivos tais como, se tratar de um procedimento complexo, com uso de alta tecnologia, a característica de cronicidade da doença renal crônica, o alto uso de medicamentos. Estratégias precisam ser tomadas de forma a otimizar o funcionamento desses acessos vasculares, pois deles depende a qualidade da diálise, consequentemente a qualidade de vida do paciente com doença rena crônica em tratamento dialítico.

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