O uso do Global Trigger Tool para rastrear os eventos adversos em uma unidade de internação pediátrica

Abstract

The patient safety issue has been discussed under different approaches and meanings, among them the issues that characterize the occurrence of adverse events in health care. Objective: To track the occurrence of adverse events using the Global Trigger Tool proposed by the Institute for Healthcare Improvement (IHI) in a pediatric inpatient unit of a teaching hospital in the city of Porto Alegre – RS. Method: Retrospective study in a comprehensive and analytical approach performed in the Pediatric Inpatient Unit (UIP) of the Hospital São Lucas of PUCRS. The sample consisted of 209 records of patient who were discharged from the UIP during the period of January to December/2013. Data collection was performed using the methodology proposed by the Institute for Healthcare Improvement (IHI). Data analysis was created a database into an Excel spreadsheet and used the SPSS software version 13.0. Data were analyzed using tables, graphs, percentages, means and standard deviations. Results: There was a predominance of male children and 124 (59.3%), moreover, found 111 (53.1%) infants and 60 (28.7%) students. It is observed that the average hospital stay was 6.9 + 18 days. Approximately 51% of children hospitalized remained for up to seven days and 22.0% for more than seven days. The patients were mostly from the pediatric emergency (63.1%) and primary care units in health (18.6%). The traced triggers, two (1.0%) cases were of C4 (positive blood culture), one (0.5%) of C14 (complication related procedure) and no cases related to trigger infections caused by health care. All triggers traced in the records fit in the category of damage E (contributed to the temporary damage and required intervention). There is no evidence record for the occurrence of adverse events and none of the identified damage had its outcome as an adverse event. The hospital outcome of 208 (99.5%) patients was the home and one patient (0.5%) was transferred to the pediatric emergency for worsening of clinical status. Conclusion: The retrospective review of medical records of methodology as a method for measurement of adverse events is a very useful tool in thinking Patient Safety, however it is necessary to adapt it to pediatric populations. Patient safety is still a challenge for health institutions, the biggest challenge of these institutions is to transform the healthcare environment for patient safety culture.