Adverse events in adult intensive care units: an integrative review
DOI:
https://doi.org/10.33448/rsd-v10i10.18523Keywords:
Adverse events; Intensive care unit.Abstract
Care in an Intensive Care Unit (ICU) is intended for critically ill patients, who, due to their complexity, are more exposed to the occurrence of adverse events (AE), usually resulting from health care such as phlebitis, medication errors and Pneumonia associated with mechanical ventilation. These AEs can cause temporary or permanent damage and their occurrence is linked to multiple factors related to the patient and work processes. It aimed to identify scientific evidence on the most frequent adverse events in ICUs. Integrative review performed in Mediline, Scopus, Scielo and Lilacs databases between April and May 2021 with a time frame from 2016 to 2021. 10 articles published in English and Portuguese were included. The results showed that the most frequent adverse events are linked to health care, highlighting the clinical processes/procedures and that there are factors that influence the occurrence of events such as: age, comorbidities, severity, greater nursing workload, disproportionate staffing. Although adverse events are considered a public health problem that is very present in intensive care units, there are still few studies on the subject.
References
, 7(2):177-87. http://www.hsj.gr/medicine/interruption-oftherapy-during-intrahospital-transport-of-non 8208icu-patients.pdf),
Brasil. Agência Nacional de Vigilância Sanitária. Medidas de Prevenção de Infecção Relacionada à Assistência à Saúde/Agência Nacional de Vigilância Sanitária. Anvisa, 2017. http://portal.anvisa.gov.br/ >
Brasil. Anvisa. Gestão de Riscos e Investigação de Eventos Adversos Relacionados à Assistência à Saúde. < http://portal.anvisa.gov.br/ >
Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. RDC ANVISA/MS nº 36, de 25 de julho de 2015. Institui ações para a segurança do paciente em serviços de saúde e dá outras providências [Internet]. Brasília: Ministério da Saúde, 2015 <http://portal.anvisa.gov.br/documents/10181/2871504/RDC_36_2013_COMP.pdf/36d809a4e5ed-4835-a375-3b3e93d74d5e 4>
Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria GM/MS nº 529, de 1 de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP) [Internet]. Brasília: Ministério da Saúde, 2013: http://bvsms.saude.gov.br/bvs/saudelegis/g m/2013/prt0529_01_04_2013.html
CASP. Critical Appraisal Skills Programme. http://www.casp-uk.net/casp-tools-checklists.2013
Costa, T. D., Salvador, P. T. C. O., Rodrigues, C. C. F. M., Alves, K. Y. A., Tourinho, F. S. V. & Santos, V. E. P. Percepção de profissionais de enfermagem acerca de segurança do paciente em unidades de terapia intensiva. Rev Gaúcha Enferm.,37(3):e61145. http://dx.doi.org/10.1590/1983- 1447.2016.03.61145.
Crossetti, M. G. O. Revisão integrativa de pesquisa na enfermagem o rigor científico que lhe é exigido. Ver. gaúcha enferm. 2012, 33(2):8-9.
Dodek, P., Norena, M., Ayas, N., Dhingra, V., Brown, G. & Wong, H. Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events. J Crit Care. 53:258-263. 10.1016/j.jcrc.2019.06.023.
Dutra, D. D., Duarte, M. C. S., Albuquerque, K. F. et al. Eventos adversos em Unidades de Terapia Intensiva: estudo bibliométrico. Rev Fund Care Online. 9(3):669-675. http://dx.doi.org/10.9789/2175- 5361.2017.v9i3.669-675
Françolin, et al. Gerenciamento da segurança do paciente sob a ótica dos enfermeiros. Rev Esc Enferm USP. 49(2):277-83. http://dx.doi.org/10.1590/S0080623420150000200013. http://www.scielo.br/pdf/reeusp/v49n2/pt_0080-6234-reeusp-49-02-0277.pdf
Gonçalves, L. A., Garcia, P. C., Toffoleto, M. C, Telles S. C. R., & Padilha, K. G. [The need for nursing care in Intensive Care Units: daily patient assessment according to the Nursing Activities Score (NAS)]. Rev Bras Enferm. http://www.scielo.br/ pdf/reben/v59n1/a11v59n1.pdf
Jhak, et al. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf. 22(10):809-15. https://qualitysafety.bmj.com/content/22/10/809>
Kelly, D. M., Kutney-Lee, A., McHugh, M. D., Sloane, D. M. & Aiken, L. H. Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults. Crit Care Med. 42(5):1089-95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3993087/ pdf/nihms570089.pdf,
Kleffman, J., Pahl, R., Deinsberger, W., Ferbert, A. & Roth, C. Intracranial pressure changes during intrahospital transports of neurocritically ill patients. Neurocrit Care. 25(3):440-5. 10.1007/s12028-016-0274-6
Knaus, W. A., Zimmerman, J. E., Facp, W., Douglas P., Draper, E. A., Lawrence, D. E. Apache - fisiologia aguda e avaliação crônica da saúde: um sistema de classificação com base fisiológica, Critical Care Medicine: 9, 591-597
Lima, C. S. P. & Barbosa, S. F. F. Ocorrência de eventos adversos como indicadores de qualidade assistencial em unidade de terapia intensiva. Rev Enferm UERJ. 23(2):221-8. http://dx.doi.org/10.12957/reuerj.2015.6076. http://www.facenf.uerj.br/v23n2/v23n2a13.pdf.
Maia, C. S., et al. Notificação de eventos adversos relacionados com a assistência à saúde que levaram a óbitos no Brasil 2014-2016. Epidemiol. Serv. Saude, 27(2):e2017320. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2237-96222018000200308&lang=pt
Maldonado, N. X., Nascimento, E. R. P. & Lazzari, D. D. Nursing professionals and adverse event reporting. Texto Contexto Enferm. 29(Spe): e20190282. https://doi.org/10.1590/1980-265X-TCE-2019-0282
Mansouri, S. F., Mohammadi, T. K., Adib, M., Lili, E. K. & Soodmand, M. Barriers to nurses reporting errors and adverse events. Br J Nurs. 28(11):690-695. 10.12968/bjon.2019.28.11.690.
Merino, P. et al. Study Investigators. Adverse events in Spanish intensive care units: the SYREC study. Int J Qual Health Care. 24:105-13. 4. https://www.ncbi.nlm.nih.gov/pubmed/22190588
Nazareno, R. M. P. F. et al. Ocorrências iatrogênicas nas Unidades de Terapia Intensiva: enfoque nas ações da equipe de enfermagem. Rev eletrônica enferm. 1 (1):1-16. 24. http://www.scielo.br/pdf/rlae/v9n5/7804.pdf
Novaretti, M. C. Z. et al. Sobrecarga de trabalho da Enfermagem e incidentes e eventos adversos em pacientes internados em UTI. Rev Bras Enferm. 67(5):692-9. http://www.scielo.br/scielo.php?pid=S0034-71672014000500692&script=sci_abstract&tlng=pt
Oxford. Centre for evidence-based medicine:levels of evidence. http://www.cebm.net/oxford-centre-evidence-levels-evidence-march-2009
Padilha, K. G. Ocorrências iatrogênicas em unidade de terapia intensiva (UTI): análise dos fatores relacionados. Rev Paul Enferm. 25 (1).
Pagnamenta, A. & et al. Adverse event reporting in adult intensive care units and the impact of a multifaceted intervention on drug-related adverse events. Ann Intensive Care. 2012, 2:47. https://www.ncbi.nlm.nih.gov/pubmed/23174137
Pompeo, D. A., Rosssi, L. A, & Galvão, C. M.(2009). Revisão integrativa: etapa inicial do processo de validação de diagnósticos de enfermagem. Acta Paulista de enfermagem, 22(4):434-8. http://doi.org/10.1590/sd103-2100200900040014.
Rodríguez, M. F., López-Izquierdo, R., Mohedano-Moriano, A., Polonio-López, B., Maestre Miquel, C., Viñuela, A., Fernández, C. D., Correas, J. G., Marques, G. & Martín-Conty, J. L. Identification of Serious Adverse Events in Patients with Traumatic Brain Injuries, from Prehospital Care to Intensive-Care Unit, Using Early Warning Scores. Int J Environ Res Public Health. 17(5):1504. 10.3390/ijerph17051504.
Roque, K. E. & et al. Eventos adversos na unidade de terapia intensiva: impacto na mortalidade e no tempo de internação em um estudo prospectivo. Cad. Saúde Pública, 32(10):e00081815, http://dx.doi.org/10.1590/0102-311X00081815. http://www.scielo.br/scielo.php?script=sci _arttext&pid=S0102-311X2016001005001&lng=en&nrm=iso.
Runciman, W. & et al.Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 21:18-26. 11. https://academic.oup.com/intqhc/article/21/1/18/1888152 >
Silva, R., Amante, L. N., Salum, N. C. & et al. Incidentes e Eventos Adversos no Transporte Intra-Hospitalar em Terapia Intensiva. 2018,8:e2805. http://dx.doi.org/10.19175/recom.v8i0.2805
Souza, V. R. & et al. O estresse de enfermeiros atuantes no cuidado do adulto na unidade de terapia intensiva. J res fundam care online. 25-8. zhttp://www.seer.unirio.br/index.php/cuidadofundamental/article/view/1687/pdf_501 >
Teodoro, R. F. B., Silva, A. S., Carreiro, M. A., Bilio, R. L. & Paula, D. G. Análise da notificação de eventos adversos através da pesquisa de cultura de segurança do paciente. Rev Fun Care Online. 12:463-470. http:// dx.doi.org/10.9789/2175-5361.rpcfo.v12.8521
Toffolleto, M. C., Barbosa, R. L., Andolhe, R., Oliveira, E. M., Ducci, A. J. & Padilha, K. G. Factors associated with the occurrence of adverse events in critical elderly patients. Rev Bras Enferm 2016,69(6):977-83. http://dx.doi.org/10.1590/0034-7167-2016-0199
Veiga, V. C., Postalli, N. F., Alvarissa, T. K. et al. Eventos adversos durante transporte intra-hospitalar de pacientes crítico. Rev Bras Ter Intensiva. 2019,31(1):15-20.
Whittemore, R. & Knaff, K. Revisão integrativa review: update methodology. Leading global nursing research, Ingaterra, 52(5):546-553, 2005
Who. World Health Organization. Summary of the evidence on patient safety: implications for research. Edição: AshishJha, https://pesquisa.bvsalud.org/portal/resource/pt/who-43874
World Health Organization (WHO). The conceptual framework for the international classification for patient safety v1.1: final technical report and technical annexes. http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Marcela Claudia de Paula Oliveira; Jeniffer Bezerra Guimarães Barreto; Virgínia Menezes Coutinho; Patrícia da Costa Araújo Magalhães
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
