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Resumo Objetivou-se analisar fatores associados ao near miss neonatal em Cuiabá, Mato Grosso. Estudo caso-controle de nascidos vivos em capital do Centro-Oeste brasileiro, de janeiro de 2015 a dezembro de 2018, com 931 casos e 1.862 controles. Os dados foram coletados no Sistema de Informações sobre Nascidos Vivos e no Sistema de Informações sobre Mortalidade. As variáveis foram organizadas seguindo o modelo hierárquico. A associação foi analisada por meio de regressão logística, com nível de significância de 5%. Os dados foram expressos em odds ratio (OR) bruta e ajustada e respectivos intervalos de confiança (IC95%). Mantiveram-se associados ao near miss neonatal: mães com duas (OR = 1,63; IC95%: 1,01-2,63) ou três ou mais gestações anteriores (OR = 1,87; IC95%: 1,09-3,21), sem nenhum filho (OR = 2,57; IC95%: 1,56-4,24) ou com um filho vivo ao nascer (OR = 1,53; IC95%: 1,04-2,26), gravidez múltipla (OR = 4,57; IC95%: 2,95-7,07), menos de seis consultas de pré-natal (OR = 2,20; IC95%: 1,77-2,72), partos realizados em hospitais públicos/universitários (OR = 2,25; IC95%: 1,60-3,15) e filantrópicos (OR = 1,62; IC95%: 1,16-2,26), apresentação não cefálica (OR = 2,71; IC95%: 1,87-3,94) e trabalho de parto não induzido (OR = 1,47 IC95%: 1,18-1,84).
Abstract We aimed to analyze factors associated with neonatal near-miss in Cuiabá, State of Mato Grosso, Brazil by performing a case-control study of live births in a capital city of central-western Brazil from January 2015 to December 2018 that included 931 cases and 1,862 controls. Data were obtained from the Live Births Information System and the Mortality Information System and variables were organized according to the hierarchical model. Association was analyzed by logistic regression with a 5% significance level. Data were expressed as crude and adjusted odds ratio (OR) and respective confidence intervals (95%CI). The following factors were associated with neonatal near miss: mothers with two (OR = 1.63; 95%CI: 1.01-2.63) or three or more previous pregnancies (OR=1.87; 95%CI: 1.09-3.21), without any live children (OR = 2.57; 95%CI: 1.56-4.24 ) or one live child at birth (OR = 1.53; 95%CI: 1.04-2.26), multiple pregnancy (OR = 4.57; 95%CI: 2.95-7.07), fewer than six prenatal consultations (OR = 2.20; 95%CI: 1.77-2.72), whose deliveries took place in public/university hospitals (OR = 2.25; 95%CI: 1.60-3.15) or philanthropic hospitals (OR = 1.62; 95%CI: 1.16-2.26), with non-cephalic presentation (OR = 2.71 95%CI: 1.87-3.94) and uninduced labor (OR = 1.47; 95%CI: 1.18-1.84).
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Resumo Este estudo, de caráter misto e sequencial exploratório, objetivou identificar padrões relacionados a trajetória de mulheres gestantes e puérperas que evoluíram para situações de risco, desde sua chegada em um primeiro serviço de assistência até sua admissão em uma maternidade terciária. A fase quantitativa analisou 1.703 prontuários e registros de internação de mulheres assistidas em três maternidades terciárias da Região Metropolitana de Fortaleza, no Ceará, entre 2010 e 2019. Na fase qualitativa, realizada entre janeiro e setembro de 2020, participaram 14 mulheres sobreviventes ao Near Miss Materno (NMM), por meio da Entrevista Narrativa Autobiográfica de Schütze. Os achados desvelam como atrasos relacionados aos profissionais e ao sistema de saúde contribuíram para a peregrinação de gestantes e puérperas e, consequentemente, para os quadros de NMM. A peregrinação destas mulheres associa-se a problemas nas estruturas da rede de atenção e dos serviços de saúde. Assim, fazem-se necessários o uso de ferramentas de acompanhamento da qualidade do serviço prestado pelos profissionais de saúde, os processos assistenciais bem estabelecidos, as estruturas físicas e as Redes de Atenção à Saúde (RAS), que suportem o seguimento desses processos.
Abstract This mixed-method and sequential exploratory study aims to identify patterns related to the trajectory of pregnant and puerperal women who evolved to risk situations, from arrival in a first care service to admission to a tertiary maternity hospital. The quantitative phase analyzed 1,703 medical records and hospitalization records of women assisted in three tertiary maternity hospitals in the Metropolitan Region of Fortaleza, Ceará, from 2010 to 2019. The qualitative phase was conducted from January to September 2020 with 14 women survivors of Maternal Near Miss (MNM), using Schütze's Autobiographical Narrative Interview. The findings reveal how delays related to professionals and the health system contributed to the pilgrimage of pregnant and postpartum women and, consequently, to the MNM cases. The peregrination of these women is associated with problems in the structures of the Care Network and the services. Thus, it becomes necessary to use tools to monitor the quality of the service provided by health professionals and to provide well-established care processes, physical structures, and the healthcare networks that support the follow-up of these processes.
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In India, there is a mandate to increase institutional delivery, which has led to an overwhelming response in health-care delivery. The maternal mortality rate has been an essential yardstick, used by health-care planners to assess the quality of obstetric services. As of late, there has been a shift in focus to maternal near-misses (MNMs) as a more valuable indicator of maternal health than the maternal mortality rate. The aim of this research article was to compare various standardized tools to address MNM, namely, the World Health Organization MNM tool, The Government of India's facility-based MNM review tool, etc.
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BACKGROUND: Despite advances in medical sciences and increased awareness of measures for safe child birth, unacceptably high maternal morbidity and mortality continues in developing countries like India. Ours being a tertiary care centre, draws a lot number of high risk pregnancies and referrals. By auditing the near miss cases2 i.e., a critically ill pregnant or recently delivered woman who was on the verge of death but survived a problem during pregnancy, childbirth, or within 42 days of the pregnancy's termination, we aim to identify the causes, factors leading to near miss2 and the management given to near miss2 and maternal deaths. The AIMS AND OBJECTIVES: present study aims to determine the magnitude, as well as to identify the pattern of Maternal Near Miss2 (MNM), at Siddhartha Medical College, Vijayawada, during the study period of two years. To anal OBJECTIVES: yse 1)Adverse events leading to a maternal near-miss2, 2) Disorders underlying these cases, 3)Sociodemographic factors and 4)Contributing factors A hospital based retros METHODOLOGY: pective observational study to assess the frequency and nature of maternal near miss2 events among the obstetric cases managed at Siddhartha Medical College, Vijayawada over a period of two years. The followi RESULTS: ng are the major causes identified leading to maternal near miss2 during our study Severe Eclampsia 17%, Post-partum Haemorrhage 17%, Pulmonary Edema due to severe pre eclampsia3 9%, Antepartum Eclampsia 9%, HELLP 9%, Ruptured ectopic pregnancy 7%, Cardiac failure 7%, Postpartum Eclampsia 7%, Imminent Eclampsia 4%, Abruption 4%, Rupture uterus 2%. In our study Maternal near miss2 ratio incidence: 0.0254, Severe maternal outcomes ratio : 3, Maternal near miss2 to mortality ratio: 0.433 CONCLUSION: We observed in majority of the cases level 1 and level 2 delays in reporting to our institution
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Background & objectives: Government of India (GoI) released operational guidelines for maternal near miss-review (MNM-R) in 2014 for use by programme managers of public health system to assist them for conducting MNM-R. The objective of the present study was to review the incidence and factors influencing MNM events in two tertiary hospitals of Maharashtra, India, as per the operational guidelines of the GoI released in 2014 and identify delays based on three-delay model to prevent such events in future. Methods: This prospective observational study was conducted in two tertiary hospitals of Maharashtra, from July 2018 to November 2020. All women during pregnancy, childbirth or postpartum upto 42 days meeting the eligibility criteria of MNM as per the 2014 GoI guidelines were included as cases (n=228), interviewed and discussed during the monthly MNM meetings at these hospitals. Results: The incidence of MNM was 11/1000 live births; the ratio of MNM to maternal deaths was 1.2:1. Leading causes of MNM were haemorrhage (36.4%) and hypertensive disorders of pregnancy (30.3%). Haemorrhage was maximum (70.6%) in abortion and ectopic pregnancies. Majority of the women (80.2%) were anaemic, of whom 32.4 per cent had severe anaemia. Eighty six per cent of women included in the study had MNM events at the time of admission and 81 per cent were referred from lower facilities. Level one and two delays were reported by 52.6 and 32.5 per cent of women, respectively. Level three delay at referral centres and at tertiary hospitals was reported by 69.7 and 48.2 per cent of women, respectively. Interpretation & conclusions: The findings of this study suggest that MNM-R should be undertaken at all tertiary hospitals in India as per GoI guidelines to identify gaps based on three-delay model. These hospitals should implement interventions as per the identified gaps with emphasis on strengthening the infrastructure, facilities and manpower at the first-referral units.
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Objective:To describe the characteristics and analyze risk factors for surgical items count near-miss errors stemming from the self-incident reports of staff nurses from operating room, to reduce the risk of counting surgical items and prevent the occurrence of the relative adverse events.Methods:This was a retrospective study. Used the self-made checklist to retrospect the surgical items count errors, relative characteristics and reasons from the operating room nurses of Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University reported from January 2017 to December 2021. Grey Relational Analysis was used to analyze and identify the risk elements.Results:A total of 98 surgical items count near-miss errors were reported by nurses.The unclear items were mainly classified into 6 categories, of which 52.04% (51/98) were disposable surgical items, 24.49% (24/98) were fine parts of surgical instruments, 14.28% (14/98) were implants, 5.10% (5/98) were electrosurgical instruments, 3.06% (3/98) were power systems, and 1.02% (1/98) were medical lasers; the disposable surgical items were the highest risk of surgical items count near-miss errors (non-standard behaviors of surgeons ξ 1=0.333); among the 9 risk factors, non-standard behaviors of surgeons ( r1 = 0.673), instrument nurses improper operation ( r4 = 0.691) and surgeons errors ( r2 = 0.693) were the most important influence factors. Conclusions:Analyzing the possible system risk factors resulting from the near-miss error could be a useful method for nurses to generate hierarchical risk-control strategies and improve surgical items count safety for patients. This com prerent the occurrence of adverse events.
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SUMMARY OBJECTIVE: The aim of this study was to evaluate and compare Maternal Near Miss prevalence and outcomes before and during the coronavirus disease 2019 pandemic. METHODS: This retrospective study was carried out in a university maternity hospital of high complexity. The population was divided into two groups: G1, 1 year before the coronavirus disease 2019 pandemic period (August 2018-July 2019) and G2, 1 year during the pandemic period (August 2020-July 2021). All pregnant/postpartum women hospitalized up to 42 days after the end of pregnancy/childbirth were included, and pregnant women who were admitted with coronavirus disease 2019/flu symptoms were excluded. The association of variables with "Maternal Near Miss" was estimated using logistic regression. RESULTS: A total of 568 women from G1 and 349 women from G2 fulfilled the Maternal Near Miss criteria. The prevalence of Maternal Near Miss in pre-pandemic was 144.1/1,000 live births and during the pandemic was 78.5/1,000 live births. In the analysis adjusted for G1, the factors of days of hospitalization (PR: 1.02, CI: 1.0-1.0, p<0.05), pre-eclampsia (PR: 0.41, CI: 1.4-2.2, p<0.05), and sepsis/severe systemic infection (PR: 1.79, CI: 0.3-0.4, p<0.05) were crucial for women with the Maternal Near Miss condition to have a greater chance of being admitted to the intensive care unit. In G2, low education (PR: 0.45, CI: 0.2-0.9, p<0.05), eclampsia (PR: 5.28, CI: 3.6-7.6, p<0.05), and use of blood products (PR: 6.48, CI: 4.7-8.8, p<0.05) increased the risk of admission to the intensive care unit. CONCLUSION: During the pandemic, there was a lower prevalence of Maternal Near Miss in high-risk pregnancies, fewer hospitalizations, and more deaths compared to the non-pandemic period.
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Abstract Objective Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity. Methods This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). Results The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5-96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2-10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0-50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6-1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7-7.9 and p = 0.0009; OR: 17.68; 95%CI: 2-153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3-440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2-26.3]). Conclusion Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.
Resumo Objetivo Lúpus eritematoso sistêmico (LES) pode causar danos irreversíveis aos órgãos. A gravidez com LES pode ter riscos para condições ameaçadoras à vida. O presente estudo teve como objetivo determinar a prevalência de MMG em pacientes com LES e analisar os parâmetros que contribuíram para os casos de maior gravidade. Métodos Trata-se de um estudo transversal retrospectivo a partir da análise de dados obtidos de prontuários de gestantes com LES atendidas em um Hospital Universitário no Brasil. As gestantes foram divididas em grupo controle sem intercorrências, grupo com condições potencialmente ameaçadoras a vida (CPAV) e grupo com near miss materno (NMM). Resultados A taxa de NMM foi de 112,9 por 1.000 nascidos vivos. A maioria dos casos de CPAV (83,9%) e NMM (92,9%) teve partos prematuros com risco aumentado estatisticamente significativo em comparação com o grupo controle (p = 0,0042; odds ratio [OR]: 12,05; intervalo de confiança [IC]: 1,5-96,6 para o grupo NMM e p = 0,0001; OR: 4,84; IC95%: 2,2-10,8 para o grupo CPAV). MMG aumenta o risco de maior tempo de internação (p < 0,0001; OR: 18,8; IC95%: 7,0-50,6 e p < 0,0001; OR: 158,17; IC95%: 17,6-1424,2 para os grupos CPAV e NMM, respectivamente), recémnascidos com baixo peso (p = 0,0006; OR: 3,67; IC95%: 1,7-7,9 e p = 0,0009; OR: 17,68; IC95%: 2-153,6 para os grupos CPAV e NMM, respectivamente), bem como doenças renais (CPAV: 58,9%; 33/56; p = 0,0069 e NMM: 78,6%; 11/14; p = 0,0026)]. Os casos de NMM apresentaram risco aumentado para óbito neonatal (p = 0,0128; OR: 38,4; IC95%: 3,3-440,3), natimorto e aborto espontâneo (p = 0,0011; OR: 7,68; IC95%: 2,2-26,3). Conclusão Lúpus eritematoso sistêmico foi significativamente associado à morbidade materna grave, internações mais longas e risco aumentado de desfechos obstétricos e neonatais ruins.
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Humans , Female , Pregnancy , Pregnancy, High-Risk , Brief, Resolved, Unexplained Event , Maternal Death , Lupus Erythematosus, SystemicABSTRACT
Introducción: La notificación de eventos adversos es reflejo de la calidad asistencial de enfermería y de la cultura de seguridad. Objetivo: Identificar la percepción de enfermería sobre la notificación de eventos adversos en cuidados intensivos pediátricos. Métodos: Estudio cualitativo, de tipo investigación convergente asistencial, realizado en la Unidad de Cuidados Intensivos del Hospital Provincial Pediátrico "José Luis Miranda", Cuba, de octubre a diciembre del año 2022. Participaron 38 enfermeras, por medio de entrevista informal, observación participante y grupo de discusión. Los datos recogidos en el proceso investigativo fueron organizados por analogía de información y analizados de forma cualitativa, ello incluyó el descubrimiento, codificación y relativización de la información, lo cual permitió identificar categorías, codificar estas categorías y establecer relaciones. Resultados: Los participantes percibían que la notificación de eventos adversos se realizaba de forma verbal al jefe de equipo de enfermería. La ausencia de notificación ocurría por desconocimiento de los aspectos de la cultura de seguridad, temor a sanciones y no existencia de un sistema de notificación. Como parte de las estrategias para la notificación de eventos adversos los enfermeros sugirieron la realización de talleres y cursos formativos sobre cultura de seguridad, crear un ambiente laboral no punitivo que favorezca el análisis y aprendizaje de cada error. Conclusión: Los profesionales de enfermería perciben que se notifican de forma espontánea los eventos adversos en cuidados intensivos, existe la necesidad de formar al personal en cultura de seguridad del paciente y diseñar un sistema de vigilancia de eventos adversos(AU)
Introduction: Adverse event reporting is a reflection of nursing care quality and safety culture. Objective: To identify nurses' perception about adverse event reporting in pediatric intensive care. Methods: A qualitative study, of convergent care research type, was carried out in the intensive care unit of Hospital Provincial Pediátrico José Luis Miranda, in Cuba, from October to December 2022. Thirty-eight nurses participated in an informal interview, with participant observation and a discussion group. The data collected in the research process were organized by information analogy, as well as qualitatively analyzed. This included the discovery, coding and relativization of the information, which allowed to identify and code these categories, as well as establishing relationships. Results: The participants perceived that adverse event reporting was done verbally to the head nurse. The lack of reporting was due to lack of knowledge about safety culture aspects, fear of sanctions and the nonexistence of a reporting system. As part of the strategies to encourage adverse events reporting, the nurses suggested holding workshops and training courses on safety culture, as well as creating a nonpunitive working environment that favors the analysis and learning from each error. Conclusion: Nursing professionals perceive that adverse events in the intensive care settings are reported spontaneously. There is a need to train such staff based on a patient safety culture and to design an adverse event surveillance system(AU)
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Humans , Intensive Care Units, Pediatric , Nursing Care/methodsABSTRACT
ABSTRACT Objective: to analyze the prevalence of practices in childbirth care, obstetric and neonatal adverse events and their association with care models in three public health services. Method: this is a prospective cohort study carried out with 548 dyads, postpartum women and their newborns, whose pregnancy was of usual risk and vaginal birth, admitted to hospital in three public services, one with an exclusive care model by nurse-midwives (service A), one with a collaborative model involving obstetric doctors and nurses (service B) and one with an exclusive medical care model (service C). Initially, an interview was carried out with participants, and a second contact was carried out 42 days after birth to complement the collection of the adverse event outcome. Results: in service A, no woman underwent the Kristeller maneuver, episiotomy, directed pushing or more than one vaginal examination per hour. Meanwhile, in service C, 19.3%, 39.9%, 77.1% and 26.3% of women underwent these interventions, respectively. Adverse events occurred in 19.2% of the dyads. Occurrence of adverse events was associated with not using partograph (p=0.001; OR: 11.03; CI: 2.64-45.99) and episiotomy (p=0.042; OR: 1.72; CI: 1. 02-2.91). The mean probability of experiencing an adverse event was 5% in service A, 21% in service B and 24% in service C. Conclusion: adverse events had a lower mean probability of occurrence in the service exclusively operated by nurse-midwives, in which greater application of recommendations for labor and birth care was identified.
RESUMEN Objetivo: analizar la prevalencia de prácticas en la atención del childbirth, eventos adversos obstétricos y neonatales y su asociación con los modelos de atención en tres servicios públicos de salud. Método: estudio de cohorte prospectivo realizado con 548 binomios, puérperas y sus recién nacidos, cuyo embarazo fue de riesgo habitual y childbirth vaginal, hospitalizados en tres servicios públicos, uno con modelo de atención exclusiva por enfermeras obstétricas (servicio A), otro con modelo colaborativo. modelo con la labor de médicos y enfermeras obstetras (servicio B) y otro con un modelo de asistencia médica exclusiva (servicio C). Inicialmente se realizó una entrevista a los participantes y se realizó un segundo contacto a los 42 días del nacimiento para complementar la recopilación del resultado del evento adverso. Resultados: en el servicio A ninguna mujer fue sometida a maniobra de Kristeller, episiotomía, pujo dirigido o más de un examen vaginal por hora. Mientras tanto, en el servicio C, el 19,3%, 39,9%, 77,1% y 26,3% de las mujeres se sometieron a estas intervenciones, respectivamente. Los eventos adversos ocurrieron en el 19,2% de los binomios. La aparición de eventos adversos se asoció con la no utilización del partographa (p=0,001; OR: 11,03; IC: 2,64-45,99) y episiotomía (p=0,042; OR: 1,72; IC: 1,02-2,91). La probabilidad promedio de experimentar un evento adverso fue del 5% en el servicio A, del 21% en el servicio B y del 24% en el servicio C. Conclusión: los eventos adversos tuvieron menor probabilidad promedio de ocurrencia en el servicio operado exclusivamente por enfermeras obstétricas, en el que se identificó mayor aplicación de las recomendaciones de asistencia al childbirth y nacimiento.
RESUMO Objetivo: analisar a prevalência de práticas na atenção ao parto, eventos adversos obstétricos e neonatais e sua associação com modelos assistenciais em três serviços de saúde públicos. Método: estudo coorte prospectivo realizado com 548 binômios, puérperas e seus recém-nascidos, cuja gestação foi de risco habitual e o parto vaginal, internados em três serviços públicos, sendo um com modelo de assistência exclusivo por enfermeiras obstetras (serviço A), um com modelo colaborativo com atuação de médicos e enfermeiras obstetras (serviço B) e um com modelo de assistência exclusiva médica (serviço C). Inicialmente, foi realizada uma entrevista com as participantes e um segundo contato foi realizado após 42 dias do parto para complementar a coleta do desfecho evento adverso. Resultados: no serviço A, nenhuma mulher foi submetida à manobra de Kristeller, episiotomia, incentivos a puxos dirigidos ou mais de um toque vaginal por hora. Enquanto, no serviço C, 19,3%, 39,9%, 77,1% e 26,3% das mulheres foram submetidas a essas intervenções, respectivamente. Os eventos adversos ocorreram em 19,2% dos binômios. A ocorrência dos eventos adversos foi associada ao não uso do partograma (p=0,001; OR: 11,03; IC: 2,64-45,99) e episiotomia (p=0,042; OR: 1,72; IC: 1,02-2,91). A probabilidade média de apresentar algum evento adverso foi de 5% no serviço A, 21% no serviço B e 24% no serviço C. Conclusão: os eventos adversos apresentaram menor probabilidade média de ocorrência no serviço com atuação exclusiva de enfermeiras obstetras, no qual se identificou maior aplicação das recomendações para assistência ao parto e nascimento.
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Abstract Objectives: to estimate the burden of parturients, fetuses and neonate's severe morbidity and mortality and investigate the association between maternal and their conceptus outcomes. Methods: retrospective cohort of 546 parturients and their conceptus in a university hospital, reference for high-risk pregnancy, in the metropolitan region II of Rio de Janeiro State from 2015 to 2017. We classified parturients according to obstetric morbidity (OM) in direct, indirect, or mixed, and their outcomes as: 1) no severity, 2) severe complication (SC), 3) critical intervention/Intensive Care Unit, and 4) greater severity -maternal near-miss (MNM) or death. We evaluated the conceptus as neonatal near-miss (NNM) and fetal and neonatal deaths. We estimated morbimortality indicators and associated factors (multinomial logistic regression). Results: OM was frequent: 29.3% indirect, 22.3% direct, and 15.8% mixed. There were eight cases of NMM, seven with direct MO. Among the conceptus: 7.5% were NNM cases and 4.4%, deaths. The risk of severe maternal outcomes was 16.8 and neonatal, 102.6/1000 live births. Mixed race, inadequate prenatal care, CG and NMM/death, were associated with NNM. Inadequate prenatal care and maternal NM/death were associated with conceptus deaths. Conclusion: even in a reference unit, sociodemographic, and health care inequalities negatively affect mothers and, consequently, their children.
Resumo Objetivos: estimar a carga de morbidade grave e mortalidade em parturientes, fetos e neonatos e investigar a associação entre os desfechos maternos e de seus conceptos. Métodos: coorte retrospectiva de 546 parturientes e seus conceptos no hospital universitário referência para gravidez de alto risco da região metropolitana II do estado do Rio de Janeiro (ERJ), de 2015 a 2017. Classificamos as parturientes segundo morbidade obstétrica (MO) em direta, indireta e mista, e seus desfechos como: 1) sem gravidade, 2) complicação grave (CG), 3) intervenção crítica/ Unidade Terapia Intensiva e 4) maior gravidade-near miss materno (NMM) ou óbito. Avaliamos os conceptos quanto a near miss neonatal (NMN), óbitos fetais e neonatais. Estimamos indicadores de morbimortalidade, e fatores de associação (regressão logística multinomial). Resultados: MO foi frequente: 29,3% indiretas, 22,3% diretas e 15,8% mista. Ocorreram oito casos de NMM, sete com MO direta. Entre os conceptos,7,5% foram casos de NMN e 4,4%, óbitos. O risco de desfecho grave materno foi 16,8 e neonatal, 102,6 p/1000 nascidos vivos. Estiveram associados ao NMN: cor parda, pré-natal inadequado, CG e NMM/óbito; e ao óbito do concepto: pré-natal inadequado e NMM/óbito. Conclusão: mesmo em situação de referência, desigualdades sociodemográficas e assistenciais afetam negativamente mães e, consequentemente, seus conceptos.
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Humans , Female , Pregnancy , Infant, Newborn , Pregnancy Complications , Maternal Mortality , Indicators of Morbidity and Mortality , Morbidity , Pregnancy, High-Risk , Fetal Death , Perinatal Death , Brazil , Cohort Studies , Health Status DisparitiesABSTRACT
Abstract Objectives: to estimate neonatal near miss rates and investigate sociodemographic, obstetric, childbirth, and neonate factors residing in a Midwest capital city. Methods: observational cohort study of live births from Cuiabá in the period of 2015 to 2018, with data from the Sistemas de Informações sobre Mortalidade e sobre Nascidos Vivos (Mortality and Live Birth Information Systems). The neonatal near miss rate was calculated according to sociodemographic, obstetric, childbirth, and neonate variables. Logistic regression model was adjusted to analyze the factors associated with neonatal near miss. Results: the neonatal near miss rate was 22.8 per thousand live births and the variables showed an association with the outcome were: maternal age 35 years or older (OR=1.53; CI95%=1.17-2.00), having fewer than six prenatal consultations (OR=2.43; CI95%=2.08-2.86), non-cephalic fetal presentation (OR=3.09; CI95%=2.44-3.92), multiple pregnancy (OR=3.30; CI95%=2.57- 4.23), no live birth (OR=1.62; CI95%=1.34-1.96) or one live birth (OR=1.22; CI95%=1.00-1.48), delivery in public/university hospital (OR=2.16; CI95%=1.73-2.71) and philanthropic hospital (OR=1.51; CI95%=1.19-1.91) and non-induced labor (OR=1.50; CI95%=1.25-1.80). Conclusion: the neonatal near miss rate was 3.04 cases for each death, and neonatal near miss was influenced by maternal characteristics, obstetric history, type of birth hospital, and delivery care organization.
Resumo Objetivos: estimar as taxas de near miss neonatal e investigar os fatores sociodemográficos, obstétricos, do parto e dos neonatos residentes em uma capital do Centro-Oeste. Métodos: estudo observacional de coorte de nascidos vivos de Cuiabá no período de 2015 a 2018, com dados dos Sistemas de Informações sobre Mortalidade e sobre Nascidos Vivos. Foi calculada a taxa de near miss neonatal conforme as variáveis sociodemográficas, obstétricas, do parto e dos neonatos. Modelo de regressão logística foi ajustado para analisar os fatores associados ao near miss neonatal. Resultados: a taxa de near miss neonatal foi 22,8 por mil nascidos vivos e as variáveis que apresentaram associação com o desfecho foram: idade materna de 35 anos ou mais (OR=1,53; IC95%=1,17-2,00), realizar menos de seis consultas de pré-natal (OR=2,43; IC95%=2,08-2,86), apresentação fetal não cefálica (OR=3,09; IC95%=2,44-3,92), gravidez múltipla (OR=3,30; IC95%=2,57-4,23), nenhum filho nascido vivo (OR=1,62; IC=1,34-1,96) ouum filho nascido vivo (OR=1,22; IC95%=1,00-1,48), parto em hospital público/universitário (OR=2,16; IC95%=1,73-2,71) e filantrópico (OR=1,51; IC95%=1,19-1,91)e trabalho de parto não induzido (OR=1,50; IC95%=1,25-1,80). Conclusão: a taxa de near miss neonatal foi de 3,04 casos para cada óbito, sendo que o near miss neonatal foi influenciado pelas características maternas, histórico obstétrico, tipo do hospital do nascimento e organização da assistência ao parto.
Subject(s)
Humans , Female , Pregnancy , Infant, Newborn , Infant Mortality , Near Miss, Healthcare , Sociodemographic Factors , Brazil , Neonatal Nursing , Birth Cohort , MidwiferyABSTRACT
A Organização Mundial da Saúde (OMS) recomenda a análise dos casos de morbidade materna severa/near miss materno como complemento às análises das mortes de mães, dado que a incidência é mais elevada e os fatores preditivos dos dois desfechos são semelhantes. Tendo em vista que as razões de mortalidade materna, no Brasil, têm se mantido constantes apesar do compromisso firmado durante a Assembleia Geral da Organização das Nações Unidas (ONU), em 2015, o objetivo deste artigo é propor um sistema nacional de vigilância de near miss materno. Propõe-se a inclusão dos eventos near miss materno na Lista Nacional de Notificação Compulsória de Doenças, Agravos e Eventos de Saúde Pública, por meio da compatibilização dos critérios diagnósticos de near miss materno, informados pela OMS, com os códigos da Classificação Internacional de Doenças (CID) para identificação dos casos. Tendo em vista que a vigilância em saúde se faz baseada em diversas fontes de informações, a notificação poderia ser feita pelos profissionais dos serviços de saúde tão logo fosse identificado um caso confirmado ou suspeito. A partir do estudo dos fatores associados aos desfechos, espera-se a avaliação mais qualificada dos serviços voltados à assistência obstétrica e consequente implementação de políticas mais eficientes de prevenção não apenas do óbito materno, mas de eventos que podem tanto causar sequelas irreversíveis à saúde da mulher quanto aumento do risco de óbito fetal e neonatal.
The World Health Organization (WHO) recommends the analysis of severe maternal morbidity/maternal near miss cases as complementary to the analysis of maternal deaths since the incidence is higher and the predictive factors of the two outcomes are similar. Considering that the reasons for maternal mortality in Brazil have remained constant despite the commitment made during the General Assembly of the United Nations in 2015, this article aims to propose a nationwide maternal near miss surveillance system. We propose the inclusion of maternal near miss events in the National List of Compulsory Notification of Diseases, Injuries, and Public Health Events, via the compatibility of the diagnostic criteria of maternal near miss, informed by the WHO, with the codes of the International Classification of Diseases for the identification of cases. Considering that health surveillance is based on several sources of information, notification could be made by health service professionals as soon as a confirmed or suspected case is identified. With the study of the factors associated with the outcomes, we expect a qualified evaluation of the services focused on obstetric care and consequent implementation of more efficient policies to prevent not only maternal death but also events that can both cause irreversible sequelae to women's health and increase the risk of fetal and neonatal death.
La Organización Mundial de la Salud (OMS) recomienda el análisis de los casos de morbilidad materna grave/near miss materno como complemento a los análisis de las muertes maternas, dado que la incidencia es más elevada y los factores predictivos de los dos resultados son similares. Teniendo en vista que las razones de mortalidad materna, en Brasil, se han mantenido constantes a pesar del compromiso firmado durante la Asamblea General de la Organización de las Naciones Unidas, en el año 2015, el objetivo de este artículo es proponer un sistema de vigilancia de near miss materno de alcance nacional. Se propone la inclusión de los eventos de near miss materno en la Lista Nacional de Notificación Obligatoria de Enfermedades, Agravios y Eventos de Salud Pública, por medio de la compatibilización de los criterios diagnósticos de near miss materno; informados por la OMS, con los códigos de la Clasificación Internacional de Enfermedades para identificación de los casos. Teniendo en vista que la vigilancia en salud se basa en diversas fuentes de Informaciones, la notificación podría ser hecha por los profesionales de los servicios de salud, tan pronto fuese identificado un caso confirmado o sospechoso. Se espera que el estudio de los factores asociados a los resultados conduzca a una evaluación más calificada de los servicios de atención obstétrica y a la consecuente implementación de políticas más eficientes de prevención no solo de la muerte materna; sino de eventos que pueden tanto causar secuelas irreversibles a la salud de la mujer como aumento del riesgo de muerte fetal y neonatal.
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Abstract Objective: The aim of this study was to investigate factors associated with neonatal near miss and mortality of the live birth cohort in the city of Rio de Janeiro, Brazil, in 2015. Methods: Population-based retrospective cohort of live births (LB) of single pregnancy with 0-27 days of follow-up. Data were obtained from the Brazilian Live Birth and Mortality Information Systems. Logistic regressions with the analytical strategy of hierarchical determination were used for cases of near miss and deaths separately. Results: The cohort was composed of 85,850 LB. For every one thousand LB, about 16 were cases of near miss and six died. Maternal level of education, skin color, and age and adequacy of prenatal care were associated with neonatal near miss; for deaths, presentation of LB at delivery, birth weight, gestational age, and five-minute Apgar score are added. Conclusions: Besides confirming the effect of low birth weight, prematurity, and asphyxia on neonatal death, socioeconomic vulnerability markers - low education level and brown or black skin colors - were associated with neonatal death and near miss. Absent or inadequate prenatal care showed a strong association with both outcomes, being stronger for neonatal death. Investments in the quality of prenatal care and reduction of disparities in health care are necessary in Rio de Janeiro.
Resumo Objetivo: Investigar fatores associados aos near miss e óbito neonatais na coorte de nascidos vivos do município do Rio de Janeiro (RJ), 2015. Métodos: Coorte retrospectiva de base populacional de nascidos vivos de gravidez única com seguimento de até 27 dias. Dados obtidos dos Sistemas de Informações sobre Nascidos Vivos e sobre Mortalidade. Foram usadas regressão logística e estratégia analítica de determinação hierárquica separadamente para casos de near miss e óbitos. Resultados: Coorte composta de 85.850 nascidos vivos. Para cada mil nascidos vivos, 16 foram casos de near miss e seis evoluíram para óbito. Escolaridade, cor da pele e idade maternas e adequação do pré-natal estiveram associadas ao near miss neonatal; para óbitos, acrescenta-se apresentação do NV no parto, peso, idade gestacional e Apgar no 5º minuto. Conclusões: Além de confirmar o efeito do baixo peso, da prematuridade e da asfixia no óbito neonatal, variáveis marcadoras de vulnerabilidade socioeconômica — baixa escolaridade e cor da pele parda ou preta — mostraram-se associadas ao óbito e ao near miss neonatal. Pré-natal ausente ou inadequado mostrou forte associação com ambos os desfechos, mais intensa para o óbito. Investimentos na qualificação do pré-natal e na redução das desigualdades na saúde são necessários no Rio de Janeiro.
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ABSTRACT Objective: To know the perception of health workers about the phenomenon of normalization of deviance in a pediatric hospital. Method: Exploratory, descriptive, and qualitative study conducted in a public pediatric hospital in northeastern Brazil in 2021. An in-depth interview was applied to 21 health workers, submitted to Thematic Categorical Content Analysis in the MAXQDA® Software. Results: 128 context units emerged from the content analysis. These data were presented in three analytical categories, which address conceptions about normalization of deviance, examples and contributing factors. The omission of the practice of hand hygiene and the correct use of personal protective equipment,and turning off alarms stand out as the main deviance perceived by health workers. As contributing factors, human factors and organizational factors prevailed. Conclusion: Workers perceive the normalization of deviance as negligence, recklessness, and violations of good practices, with consequences for patient safety.
RESUMEN Objetivo: Conocer la percepción de los trabajadores de la salud sobre el fenómeno de la normalización de la desviación en un hospital pediátrico. Método: Estudio exploratorio, descriptivo y cualitativo realizado en un hospital pediátrico público en el noreste de Brasil en 2021. Se aplicó una entrevista en profundidad a 21 trabajadores de la salud, sometidos al Análisis de Contenido Categórico Temático en el Software MAXQDA®. Resultados: 128 unidades de contexto surgieron del análisis de contenido. Estos datos se presentaron en tres categorías analíticas, que abarcan conceptos sobre la normalización de la desviación, ejemplos y factores contribuyentes. La omisión de la práctica de la higiene de manos y el uso correcto de los equipos de protección personal y el apagado de alarmas se destacan como las principales desviaciones percibidas por los trabajadores de la salud. Como factores contribuyentes prevalecieron los factores humanos y los factores organizacionales. Conclusión: Los trabajadores perciben la normalización de la desviación como negligencia, imprudencia y violación de las buenas prácticas, con consecuencias para la seguridad del paciente.
RESUMO Objetivo: Conhecer a percepção de trabalhadores de saúde sobre o fenômeno da normalização do desvio em um hospital pediátrico. Método: Estudo exploratório, descritivo e qualitativo realizado em hospital público pediátrico do nordeste brasileiro em 2021. Aplicou-se entrevista em profundidade a 21 trabalhadores de saúde, submetida à Análise de Conteúdo Categorial Temática no Software MAXQDA®. Resultados: Emergiram 128 unidades de contexto da análise de conteúdo. Esses dados foram apresentados em três categorias analíticas, as quais abordam concepções sobre normalização do desvio, exemplos e fatores contribuintes. Destacam-se a omissão da prática de higienização das mãos e do uso correto dos equipamentos de proteção individual, e o desligamento de alarmes como principais desvios percebidos pelos trabalhadores de saúde. Como fatores contribuintes, preponderaram os fatores humanos e os fatores organizacionais. Conclusão: Os trabalhadores percebem a normalização do desvio como negligência, imprudência e violações de boas práticas, com consequências para a segurança do paciente.
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Resumo Objetivo Sintetizar e avaliar criticamente as evidências científicas oriundas de estudos observacionais sobre sistemas de biovigilância e notificação de eventos adversos na doação e transplante de órgãos. Métodos Revisão sistemática de estudos observacionais seguindo as recomendações das Diretrizes Metodológicas (REBRATS) e Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Foram incluídos estudos primários e relatos de caso conduzidos sobre biovigilância e/ou eventos adversos na doação e/ou transplante de órgãos, sem restrição de data de publicação ou idioma. Foram utilizadas seis bases de dados eletrônicas para a realização das buscas na literatura científica: - Medical Literature Analysis and Retrieval System Online (MEDLINE) (via PubMed), Excerpta Medica Database (Embase), Web of Science, LILACS, Scopus e a biblioteca eletrônica Scielo. Realizou-se também busca de dados nas seguintes bases secundárias: Notify - World Health Organization (WHO), Organização Pan-Americana de Saúde (OPAS) e Google Scholar. Para a avaliação da qualidade dos estudos foi utilizada a ferramenta MINORS. Resultados Foram identificados 551 estudos, após as etapas de avaliação, foram incluídos oito deles para a revisão sistemática. Estes foram divididos entre resultados, processos e estratégias de prevenção de eventos adversos. Quanto a classificação da qualidade dos estudos, dois obtiveram classificação boa. Conclusão Os resultados apontam a ocorrência de eventos adversos ocorridos em alguma etapa do processo de doação e transplante de órgãos e tecidos, como: reações adversas relacionadas a medicamentos; neurotoxicidade; aumento do tempo de hospitalização; reintervenções cirúrgicas; queda; coma; óbito; falha ou perda do enxerto. Destaca-se que os eventos adversos possivelmente ainda são subnotificados.
Resumen Objetivo Sintetizar y evaluar críticamente las evidencias científicas provenientes de estudios observacionales sobre sistemas de biovigilancia y notificación de eventos adversos en la donación y trasplante de órganos. Métodos Revisión sistemática de estudios observacionales guiada por las recomendaciones de las Directrices Metodológicas (REBRATS) y Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Se incluyeron estudios primarios y relatos de caso realizados sobre biovigilancia o eventos adversos en la donación o trasplante de órganos, sin restricción de fecha de publicación o idioma. Se utilizaron seis bases de datos electrónicas para realizar las búsquedas en la literatura científica: Medical Literature Analysis and Retrieval System Online (MEDLINE) (via PubMed), Excerpta Medica Database (Embase), Web of Science, LILACS, Scopus y la biblioteca electrónica Scielo. También se realizó la búsqueda de datos en las siguientes bases secundarias: Notify - World Health Organization (WHO), Organización Panamericana de la Salud (OPS) y Google Scholar. Para evaluar la calidad de los estudios se utilizó la herramienta MINORS. Resultados Se identificaron 551 estudios y, luego de las etapas de evaluación, se incluyeron ocho en la revisión sistemática, que fueron divididos entre resultados, procesos y estrategias de prevención de eventos adversos. Respecto a la clasificación de la calidad de los estudios, dos obtuvieron una clasificación buena. Conclusión Los resultados indican casos de eventos adversos ocurridos en alguna etapa del proceso de donación y trasplante de órganos y tejidos, como: reacciones adversas relacionadas con medicamentos, neurotoxicidad, aumento del tiempo de hospitalización, reintervenciones quirúrgicas, caída, coma, fallecimiento, falla o pérdida del injerto. Se destaca que los eventos adversos probablemente aún son subnotificados.
Abstract Objective To synthesize and critically evaluate the scientific evidence from observational studies on biosurveillance systems and adverse event reporting in organ donation and transplantation. Methods Systematic review of observational studies following the recommendations of the Methodological Guidelines (REBRATS) and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Primary studies and case reports on biosurveillance and/or adverse events in organ donation and/or transplantation, without restriction of publication date or language were included. Six electronic databases were used in the scientific literature search: Medical Literature Analysis and Retrieval System Online (MEDLINE) (via PubMed), Excerpta Medica Database (Embase), Web of Science, LILACS, Scopus and the electronic library Scielo. A data search was also performed in the following secondary databases: Notify - World Health Organization (WHO), Pan American Health Organization (PAHO) and Google Scholar. The MINORS tool was used to assess the quality of studies. Results 551 studies were identified, and after the evaluation steps, eight of them were included in the systematic review. These were divided into results, processes and strategies for preventing adverse events. Regarding the classification of the quality of studies, two obtained a good classification. Conclusion The results indicate the occurrence of adverse events at some stage of the organ and tissue donation and transplantation process, such as: adverse drug-related reactions; neurotoxicity; longer length of hospital stay; surgical reinterventions; falls; coma; death; graft failure or loss. The fact that adverse events are possibly still underreported is noteworthy.
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Objetivo: sumarizar os principais fatores de risco relacionados ao near miss materno. Método: revisão integrativa da literatura. A busca foi efetuada em 21 de março de 2021, nas bases de dados: NationalLibrary of Medicine - Medline via PubMed; Current Index to Nursing and Allied Health Literature; Science Direct,Elservier's Scopus, Web of Science e no portal da Biblioteca Virtual de Saúde. Os estudos foram avaliados com a Hierarchy of Evidence for Intervention Studies. Resultados: 12 artigos compuseram a revisão, todos de método quantitativo e idioma inglês. As evidências destacaram como risco para near miss materno: distúrbios hipertensivos, complicações hemorrágicas e a sepse puerperal. Demais achados relacionam-se à distância da moradia e dificuldade de acesso aos serviços de saúde além da baixa escolaridade. Conclusões: os fatores de risco para near miss materno se relacionam com pré-natal inadequado, decorrente de questões geográficas e falta de acesso aos serviços, questões econômicas, educacionais e sociais.
Subject(s)
Near Miss, Healthcare , Pregnancy Complications , Maternal Mortality , Morbidity , NursingABSTRACT
An observational study was performed at Purba Medinipur District Hospital, West Bengal, from April 1, 2018, to December 31, 2020, with an aim to find out the magnitude of maternal mortality and near miss cases and to assess the utilization of available maternal health care services by the deceased women and near miss cases. Result showed 4.5% women developed potentially life?threatening condition (PLTC) of which 21% women developed LTC. Maternal Near Miss (MNM) ratio was 9.46/1000 live birth and the MNM?to?Maternal Mortality ratio was 8.3:1 and the leading causes of MNM and maternal death were hemorrhage, pregnancy induced hypertension/eclampsia. The utilization of maternal health?care services revealed that there is a scope to increase the service delivery. Study finding indicates that health?care programs need to enhance the existing efforts to improve timely health seeking behavior of women
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Background:A maternal near miss case is defined as a “a woman who nearly died but survived a complication that occurred during pregnancy,child birth or within 42 days of termination of pregnancy”1.MMR is defined as ratio of number of maternal deaths per 1000 live births. All pregnant women deserve a good quality of care especially Emergency Obstetric Care including proper infrastructure, human resources that can detect and manage such complications earliest. The objective of this study was to evaluate the causes of maternal near miss cases, various management modalities performed and maternal and fetal outcome in near miss cases. Material And Methods:A retrospective study was carried out in obstetrics and gynaecology department of SCL municipal general hospital, Ahmedabad for identification of MNM as per MNM-R operational guidelines (2014) in a tertiary care hospital from August 2020 to March 2022. Result:Total deliveries during our study period were 9266 out of which 535 number of patients developed complications, 75 patients ended up becoming near miss cases and 30 maternal mortalities were observed.Hypertensive disorders (38.6%) followed by severe anemia (18.6%) and haemorrhage (13.3%) were the commonest underlying causes leading to MNM. More than one management modality was followed in one case. 25% of patients required blood transfusion. Out of which 11 patients required massive blood transfusion (>5 units of blood) and 16% of patients required blood products along with blood resulting from either severe anemia or altered coagulopathy (DIC). 69.3% of patients required ICU stay of <5 days and majority of patients required hospital stay of 9-14 days.63.6% of patients required ICU stay of 1-4 days.Live birth rate was 82.6%.Conclusion:Maternal health is the direct indicator of prevailing health status in a country. Reduction in maternal mortality is one of the targets of MILLENIUM DEVELOPMENT GOALS13for 2015 but in spite of full efforts by all the health care professionals, it still remains a challenge in developing countries.There should be prompt and proper management of high-risk groups by frequent antenatal visits. Aggressive management of each complication and close monitoring of women in labour, decision making in mode and time of termination of pregnancy are important to prevent further complications.
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Abstract Background: Due to many antineoplastic drugs' toxicity and narrow therapeutic window, medication errors are a health concern in pediatric oncology patients. This study aimed to identify and classify medication errors in a pediatric inpatient chemotherapy facility and evaluate the outcomes of these medication errors. Methods: We conducted an observational retrospective study over 5 months in a chemotherapy facility for pediatric patients. The evaluation consisted of the review of the available medical records. The medication errors detected were manually recorded in a medical logbook. The International Classification for Patient Safety was adjusted to our clinical setting for the analysis, the terminology, and the classification system. A descriptive analysis was performed. Results: A total of 286 medical records were reviewed; one type of medication error was noted in at least 97.6%, and 962 errors were identified totally, with an overall rate of 3.36 errors per visit. Most errors occurred in the documentation stage (643; 66.8%), followed by the administration stage (227; 23.6%). Of all medication errors, 37.2% had the potential to cause injury, but only five reached the patient (0.5%), and only two (0.2%) resulted in a severe harmful incident. Conclusions: Medication errors were common, especially at the documentation stage. Better documentation strategies need to be implemented to reduce the rate of near misses and prevent potential adverse events.
Resumen Introducción: Los errores de medicación son un problema de salud en niños con cáncer debido a la toxicidad y a la estrecha ventana terapéutica de muchos fármacos antineoplásicos. El objetivo de este estudio fue identificar y clasificar los errores de medicación en un centro de quimioterapia para pacientes pediátricos hospitalizados, así como evaluar los resultados de estos errores de medicación. Métodos: Se llevó a cabo un estudio observacional retrospectivo realizado durante un periodo de 5 meses en un centro de quimioterapia para pacientes pediátricos. La evaluación consistió en la revisión de las historias clínicas disponibles. Los errores de medicación detectados fueron registrados manualmente en una bitácora. Para el análisis, la terminología y el sistema de clasificación, la Clasificación Internacional para la Seguridad del Paciente se ajustó a nuestro entorno clínico. Se realizó un análisis descriptivo. Resultados: Se revisaron 286 historias clínicas; se observó un tipo de error de medicación al menos en el 97.6%. En total se identificaron 962 errores de medicación, con una tasa general de 3.36 errores por visita. En la etapa de documentación fue donde más errores ocurrieron (643; 66.8%), seguido de la etapa de administración (227; 23.6%). De todos los errores de medicación, el 37.2% tuvo el potencial de causar lesiones, pero solo cinco llegaron al paciente (0.5%) y solo dos (0.2%) provocaron un incidente dañino severo. Conclusiones: Los errores de medicación fueron comunes, especialmente en la etapa de documentación. Es necesario implementar mejores estrategias de documentación para reducir la tasa de cuasi accidentes y prevenir posibles eventos adversos.