Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study / Eventos adversos en una unidad de cuidados intensivos: impacto en la mortalidad y en el tiempo de internamiento en un estudio prospectivo / Eventos adversos na unidade de terapia intensiva: impacto na mortalidade e no tempo de internação em um estudo prospectivo

Abstract: This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence.

Resumen: Este estudio tuvo como objetivo evaluar la ocurrencia de eventos adversos y el impacto de los mismos sobre el tiempo de permanencia y mortalidad en una unidad de cuidados intensivos (UCI). Se trata de un estudio prospectivo, desarrollado en un hospital universitario de Río de Janeiro, Brasil. La cohorte estaba formada por 355 pacientes mayores de 18 años admitidos en la UCI, durante el período del 1º agosto de 2011 al 31 de julio de 2012. El proceso de identificación de eventos adversos se basó en una adaptación del método propuesto por el Institute for Healthcare Improvement. La regresión logística fue utilizada para analizar la asociación entre la ocurrencia de evento adverso y el óbito, ajustado por la gravedad del paciente. Se confirmaron 324 eventos adversos en 115 pacientes internados a lo largo de un año de seguimiento. La tasa de incidencia fue de 9,3 eventos adversos por 100 pacientes-día y la ocurrencia de evento adverso impactó en el aumento del tiempo de internamiento (19 días) y en la mortalidad (OR = 2,047; IC95%: 1,172-3,570). Este estudio destaca el serio problema de los eventos adversos en la asistencia a la salud prestada en cuidados intensivos y los factores de riesgo asociados a la incidencia de eventos.

Resumo: Este estudo teve como objetivo avaliar a ocorrência de eventos adversos e o impacto deles sobre o tempo de permanência e a mortalidade na unidade de terapia intensiva (UTI). Trata-se de um estudo prospectivo desenvolvido em um hospital de ensino do Rio de Janeiro, Brasil. A coorte foi formada por 355 pacientes maiores de 18 anos, admitidos na UTI, no período de 1º de agosto de 2011 a 31 de julho de 2012. O processo de identificação de eventos adversos baseou-se em uma adaptação do método proposto pelo Institute for Healthcare Improvement. A regressão logística foi utilizada para analisar a associação entre a ocorrência de evento adverso e o óbito, ajustado pela gravidade do paciente. Confirmados 324 eventos adversos em 115 pacientes internados ao longo de um ano de seguimento. A taxa de incidência foi de 9,3 eventos adversos por 100 pacientes-dia, e a ocorrência de evento adverso impactou no aumento do tempo de internação (19 dias) e na mortalidade (OR = 2,047; IC95%: 1,172-3,570). Este estudo destaca o sério problema dos eventos adversos na assistência à saúde prestada na terapia intensiva e os fatores de risco associados à incidência de eventos.

Repercusión de las complicaciones mayores posoperatorias en pacientes operados de tórax / Repercussion of major postoperative complications in patients undergoing thoracic surgery

Introducción: las complicaciones en la cirugía de tórax (pulmón, mediastino, esófago) se han asociado con un incremento en la morbilidad y la mortalidad. No se conoce cuál es la influencia de estas en la evolución de estos pacientes. Objetivo: determinar la influencia de las complicaciones mayores posoperatorias en la evolución a corto plazo de los pacientes sometidos a cirugía tóraco-mediastinal-esofágica. Métodos: se realizó un estudio de cohorte retrospectivo. De las bases de datos de la Unidad de Cuidados Intensivos y hospitalaria, entre marzo y octubre del 2013, se estudiaron a los enfermos sometidos a cirugía tóraco-mediastinal-esofágica, se identificó la ocurrencia de complicaciones mayores posoperatorias durante la estadía hospitalaria. Se precisó el tipo de complicación y su influencia en la evolución de los enfermos. Resultados: de 50 pacientes analizados, con una mediana de edad de 58,50 años (RIQ 48-65 años), a 30 (60 por ciento) se les realizó resección pulmonar, a 11 (22 por ciento) cirugía torácica sin resección pulmonar (mediastino y otras) y la cirugía esofágica se le practicó a 9 sujetos (18 por ciento). En 10 pacientes (20 por ciento) se presentó alguna complicación mayor posoperatoria, con 13 complicaciones en total, 7 de carácter médico (53,85 por ciento) y 6 quirúrgicas (46,15 por ciento). Las complicaciones más frecuentes fueron la hemorragia posoperatoria (40 por ciento), la neumonía nosocomial (20 por ciento) y las arritmias cardiacas (20 por ciento). Murieron 4 pacientes, fundamentalmente por complicaciones médicas. Las complicaciones mayores posoperatorias disminuyeron las probabilidades de alta hospitalaria (HR de 0,376 [95 por ciento IC: 0,173-0,815]; p= 0,013). Conclusiones: la frecuencia de las complicaciones mayores posoperatorias en la cirugía tóraco-mediastinal-esofágica fue relativamente alta en esta serie. La mortalidad fue más frecuente en los pacientes con complicaciones médicas. Las complicaciones mayores incrementaron significativamente la estadía en cuidados críticos y hospitalarios(AU)

Segurança do paciente em terapia intensiva: caracterização de eventos adversos em pacientes críticos, avaliação de sua relação com mortalidade e identificação de fatores de risco para sua ocorrência / Patient safety in intensive care: characterization of adverse events in critically ill patients, evaluation of their relationship with mortality and identification of risk factors for their occurrence

Introdução: A segurança do paciente é tema de grande importância pois muitos pacientes hospitalizados são vítimas de eventos adversos (EAs). Evento adverso é um incidente que resulta em dano desnecessário ao paciente, de caráter não intencional, e que está associado à assistência prestada, e não com a evolução natural da doença do indivíduo. As unidades de terapia intensiva (UTIs) são ambientes propícios à ocorrência de EAs, porém não há dados abrangentes sobre EAs em UTIs no Brasil. Além disso é preciso verificar se a ocorrência de EAs é fator de risco para morte em UTI, e quais são os fatores de risco para sua ocorrência. Objetivos: Identificar e caracterizar EAs em UTIs do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), avaliar se há relação entre ocorrência de EAs e morte em UTIs, e identificar quais os fatores de risco para a ocorrência de EAs nesses locais. Métodos: Estudo observacional do tipo coorte que analisou admissões consecutivas em UTIs no HC-FMUSP entre Junho e Agosto de 2009. Os casos foram acompanhados até a saída da UTI, seja alta ou óbito. Foram coletados dados sobre aspectos clínicos, escores de gravidade (APACHE II, SAPS II, SOFA), carga de trabalho de enfermagem (NAS) e intervenções realizadas. EAs foram identificados através da revisão de prontuários e observação dos profissionais médicos e de enfermagem, sendo classificados quanto ao tipo e grau de dano conforme classificação da Organização Mundial da Saúde. Foi feita análise multivariada com regressão logística para analisar se EAs são fatores de risco independentes para morte em UTI. Foi feita uma segunda análise multivariada com regressão logística para verificar quais são os fatores de risco para ocorrência de EAs com alto grau de dano (AGD). Resultados: Ocorreram 1126 EAs em 81,7% das 202 admissões estudadas. Os EAs mais frequentes foram os das categorias processo clínico/procedimento (54% dos EAs), medicação (25,8%), nutrição (13,9%)...

Introduction: Patient safety is a matter of great importance because many hospitalized patients are victims of adverse events (AEs). Adverse event is an unintentional incident that results in unnecessary patient harm, that is associated with the care provided, and not with the natural evolution of the individual's disease. The intensive care units (ICUs) are prone environments to the occurrence of AEs, but there is no comprehensive data on AEs in ICUs in Brazil. Is not known for sure if AEs are risk factors for death in ICUs, and what are the most important risk factors for AEs occurrence in ICUs. Objectives: To identify and characterize AEs in ICUs of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), to evaluate relationship of AEs with death in ICUs, and to identify risk factors for the occurrence of AEs. Methods: This is an observational cohort study of consecutive admissions to ICUs of HC-FMUSP analyzed between June and August 2009. The cases were followed until discharge from the ICU, dead or alive. Data on clinical features, severity scores (APACHE II, SAPS II, SOFA), nursing workload (NAS) and interventions were collected. AEs were identified by reviewing medical records and observation of medical and nursing professionals, and they were classified according to type and degree of harm as classified by the World Health Organization. Multivariate analyzes were performed with logistic regression to examine whether EAs are independent risk factors for death in the ICU. A second multivariate logistic regression analysis was performed to verify what are the risk factors for the occurrence of AEs with high damage (HD). Results: There were 1126 AEs in 81.7% of 202 admissions studied. 1126 AEs occurred in 81.7% of 202 admissions studied. The most common AEs were the categories of clinical process / procedure (54% of AEs), medication (25.8%), nutrition (13.9%), and healthcare-associated infection (5.5%)...

Medical adverse events in elderly hospitalized patients: a prospective study

OBJECTIVES: To determine the frequency of medical adverse events in elderly patients admitted to an acute care geriatric unit, the predictive factors of occurrence, and the correlation between adverse events and hospital mortality rates. METHODS: This prospective study included 171 admissions of patients aged 60 years and older in the acute care geriatric unit in a teaching hospital in Brazil between 2007 and 2008. The following variables were assessed at admission: the patient age, gender, number of prescription drugs, geriatric syndromes (e.g., immobility, postural instability, dementia, depression, delirium, and incontinence), comorbidities, functional status (evaluated with the Katz Index of Independence in Activities of Daily Living), and severity of illness (evaluated with the Simplified Acute Physiology Score Il). The incidence of delirium, infection, mortality, and the prescription of potentially inappropriate medications (based on the Beers criteria) were assessed during hospitalization. An observer who was uninvolved in patient care reported the adverse events. RESULTS: The mean age of the sample was 78.12 years. A total of 187 medical adverse events occurred in 94 admissions (55%). The predictors of medical adverse events were undetermined. Compared with the patients with no adverse events, the patients with medical adverse events had a significantly longer hospital stay (21.41 ± 15.08 days versus 10.91 ± 7.21 days) and a higher mortality rate (39 deaths [41.5%] versus 17 deaths [22.1%]). Mortality was significantly predicted by the Simplified Acute Physiology Score II score (odds ratio [OR] = 1.13, confidence interval [CI] 95%, 1.07 to 1.20), the Katz score (OR=1.47, CI 95%, 1.18 to 1.83), and medical adverse events (OR = 3.59, CI 95%, 1.55 to 8.30). CONCLUSION: Medical adverse events should be monitored in every elderly hospitalized patient because there is no risk profile for susceptible patients, and the consequences of adverse events are serious, sometimes leading to longer hospital stays or even death.

El error médico: eventos adversos / Medical error: adverse events

En la actualidad, la seguridad de los pacientes durante el proceso de atención médica ha alcanzado una relevancia prioritaria, determinando la necesidad urgente de garantizarles que sus necesidades de salud se vean satisfechas en las mejores condiciones posibles, sin verse complicadas por eventos adversos ocurridos durante el proceso de la atención. En el presente documento se proponen definiciones de los términos error médico, criterio médico, evento adverso y evento centinela, a fin de manejar conceptos semejantes. Se presenta la secuencia de eventos que puede conducir a la toma de una decisión correcta o incorrecta, el error consecuente y su derivación hacia un evento adverso, con daño para el paciente. Se hace énfasis en que la práctica médica está inmersa en un paradigma biológico impredecible, adaptativo, reactivo y creativo, a diferencia de las ciencias físico-matemáticas, que están dentro de un paradigma sujeto a leyes matemáticas, predecible y estructurado. Como consecuencia de esto, en la práctica médica cada paciente es una situación inédita que requiere de todos los conocimientos, habilidades y experiencias, para satisfacer sus necesidades de salud particulares, especialmente en situaciones críticas. Se proponen los medios para protegerse del error médico, incluyendo las guías clínicas, la medicina basada en evidencias, el mantenimiento de la competencia profesional a través de capacitación y actualización continuas, la relación médico-paciente estrecha, el estudio clínico completo y los registros escrupulosos en el expediente clínico. Como consecuencia de los errores médicos, con frecuencia se da lugar a eventos adversos que representan daño para la salud del paciente, o eventos centinela, que pueden tener consecuencias graves para la salud, la integridad o la vida del paciente. Se hace énfasis en que los eventos adversos pueden presentarse sin que esté de por medio un error médico, sino por fallas en la estructura y en los sistemas, incluyendo...

At the present time, care the patients safety during across the process of health is a priority target and determine the urgent necessity, to guarantee the satisfaction of their health needs, on best conditions as possible as it is, without complications for adverse events occurring in the medical attention. This paper purpose definition of different concepts like medical error, medical criteria, adverse and sentinel event, in order to define these concepts. Also try to show the sequence of events for a correct or incorrect medical decision, the consequent mistake and the possibility to produce an adverse event, with patient's damage. An important goal is that the medical practice is immersing in a biological paradigm, define like unpredictable, suitable, reactive and creative; very different to the exact science that has a predictable and structured paradigm, supported in mathematical rules. In the medical practice, each patient is an inedited situation and required all the knowledge, skills and experience in order to satisfy specific health needs, particularly in critical moments. The way for protect from the occurrence of medical error include the clinical practices guidelines, evidence-based medicine, the maintenance of professional competences by the continuous training, the close medical-patient relationship, integral approach of the illness and scrupulous data at the clinical record. In consequence, very often medical errors produce adverse events with damage of patients, or sentinel events with serious consequences of health, integrity or patient's life. Is important to say that the adverse events could be appear even without a medical error, just for failures in structural and systems issues, including resources and it's maintaining, organizational variables, communication, human resources, training programs, process without standardization, failures an supervision or control phases. This paper shows current adverse and sentinel events, and...

Factores asociados a mortalidad en cirugía mayor: análisis retrospectivo en un centro de referencia / Mortality associated factor in major surgery: retrospective analysis in a referral center

Background. There are very few studies that analyze surgical morbidity and mortality in the general population and the factors associated with those events. Objective. To determine factors associated to mortality in surgical procedures performed in a tertiary referral center in Mexico City. Methods. We retrospectively analyze surgical mortality in 4,157 consecutive surgical procedures performed in a one-year period from 1/1/2000 through 12/31/2000. Categorical variables were analyzed with the chi-square test and continuous variables with the t-Student test. Significance was defined as p < O.OB. Results. During the study period there were 76 postoperative deaths, representing a mortality rate of 1.82%. Mean patient's age in the entire cohort was 48.7 ± 17.6 years and for the patients who died in the postoperative period 57.8 ± 17.8 years (p < 0.05). Sixty-six percent of deaths were attributed to the primary or surgical disease. In 33.8% of postoperative deaths an adverse event was identified as responsible for the outcome. In 23% of cases there was a potentially preventable event, representing 0.3% of surgical procedures. Most patients (96.9%) had at least one co-morbid condition and 61.5% had two or more. Almost 80% of surgical deaths occurred in patients with ASA score III of TV and albumin levels below 3.5 g/dL. Most common cause of death was sepsis, reported in 35% of patients who died in the postoperative period. Conclusion. Surgical mortality in our series is low. In 0.3% of procedures it was detected a potentially preventable event. Postoperative deaths occurred in older patients with low albumin levels.

Introducción. Existen pocos estudios que analicen la mortalidad quirúrgica general y los factores asociados a la misma. Objetivo. Estudiar las causas y factores asociados a mortalidad quirúrgica en las intervenciones quirúrgicas realizadas en el INCMNSZ. Métodos. Se analizó en forma retrospectiva la mortalidad quirúrgica asociada a 4,157 procedimientos consecutivos realizados del 1/1/2000 al 31/12/2000. Los factores asociados a mortalidad fueron analizados mediante la prueba de chi-cuadrada para variables categóricas y t de Student para variables continuas. Se estableció como significativa a p < 0.05. Resultados. Durante ese periodo ocurrieron 76 muertes postoperatorias, lo que representa una mortalidad global de 1.82% para todos los procedimientos. El promedio de edad para los 4,157 procedimientos fue de 48.7 ± 17.6 años y para las muertes postoperatorias fue de 57.8 ± 17.8 años (p < 0.05). El 66.2% de las muertes se atribuyeron a la enfermedad de base o a la patología que motivó la cirugía. En 33.8% de las muertes se identificó algún evento diferente a la enfermedad primaria como responsable de la muerte. En 23% se identificó algún evento potencialmente prevenible, lo que representa 0.3% del total de eventos quirúrgicos. El 96.9% de los pacientes tenía al menos una comorbilidad y 61.5% cursaba con dos o más. El 78.5% de las muertes sucedió en pacientes ASA III-IV. El 80% de las muertes se asoció a niveles preoperatorios de albúmina por debajo de 3.5 g/dL. La causa de muerte más frecuentemente reportada fue sepsis en 35% de los eventos. Conclusión. La mortalidad postoperatoria en nuestra serie es baja. En 0.3% de los pacientes sometidos a cirugía se detectó algún evento potencialmente prevenible. Las muertes postoperatorias ocurrieron en pacientes más viejos y con niveles bajos de albúmina.