ABSTRACT
Objective
To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care.
Method
Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital.
Results
A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube – removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter – agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury – agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation – weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%).
Conclusion
The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.
Patient Harm; Hospitalization; Equipment and Supplies; Nursing Care; Patient Safety