Segurança do paciente em uma unidade de hemodiálise: análise de eventos adversos
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Data
2014-09-30
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Universidade Federal de Goiás
Resumo
INTRODUCTION: Health care comes accompanied with potential to cause adverse
events (AE) and compromising patient safety. In hemodialysis units there are
numerous risk factors that increase the potential of occurrence of these events,
suggesting that the supply of safe care to this population presents some exclusive
challenges, beyond generic questions of patient safety common to all health
establishments. OBJECTIVES: To analyze the occurrence of AE related to
hemodialysis treatment. METHODOLOGY: Sectional study, conducted in a
hemodialysis unit of a teaching hospital of Goiás. Data collection occurred between
March and September 2013, by analyzing the records of the evolution of the
hemodialysis sessions, from medical records of patients attended between January
and December, 2012 in the unit. Was used an instrument in which were transcribed
information related to the patient, treatment and possible AE. Participated in the
study 117 patients, all obeyed the inclusion criteria. The analysis of the records was
conducted by one researcher and two external reviewers, independently. Statistical
analysis was performed using SPSS version 19.0 for Windows. The study was
approved by the Research Ethics Committee and obeyed regulatory standards of
Resolution 466/2012. RESULTS: Among the 117 patients who participated of the
study, 60.7% were male, aged 01-89 years, mean 42 years, median 45 years; 79.5%
had chronic renal failure; 21.4% had a diagnosis of diabetic nephropathy as primary
renal disease and 4.3% had positive serology for hepatitis B. About the treatment
50.4% had 3.5 hours of session; 87.2% of patients received treatment three times a
week and 56.4% had up to three months of treatment, with a median of 02 months.
Of the total of 5,938 analyzed hemodialysis sessions was identified in 1,036 at least
one record of AE in 94 patients, totaling 1,272 AE. The prevalence of AE per patient
was 80.3% and the AE by hemodialysis session was 17.4%. The most prevalent AE
were inadequate blood flow (40.6%), bleeding from the venous access (11.6%),
infection/signs of infection (9.6%) and clotting in the extracorporeal system (7.1%). In
relation to damage caused 76.1% were classified as mild, 22.9% as moderate, 0.9%
as severe and 0.1% death. It was evident as an independent variable associated with
the AE to be aged 43 years or more. Was found positive correlation between the
number of AE per month and number of sessions per month, indicating that the
greater the number of hemodialysis, greater the number of EA sessions.
CONCLUSION: The investigation has identified a high prevalence of adverse events
related to hemodialysis pointing out that there is need to review the care processes
and develop actions to identify and control risk situations, as a way to establish more
secures procedures and ensure the quality of care.
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Citação
SOUSA, M. R. G. Segurança do paciente em uma unidade de hemodiálise: análise de eventos adversos. 2014. 107 f. Dissertação. (Mestrado em Enfermagem)–Universidade Federal de Goiás, Goiânia, 2014.