Aplicação de check list ampliado para detecção de incidentes de segurança do paciente em medicina perinatal

Abstract

Patient safety is one of the dimensions of quality that has received increasing attention in recent years. The incident detection in patient safety aims to improve the quality of patient care. Incidents and adverse events (AEs) of patient safety should be reported spontaneously contributing for the apprenticeship and to create barriers so that they would not be repeated, but the fear of prosecution and punishment cause its underreporting. The objective of this study was to evaluate the incidence of patient safety incidents in the perinatal period with the use of an extended check list. This research used the inductive method, empirical approach with exploratory, descriptive, cross and as a strategy action research. Population sample was composed by admitted patients in the perinatal unit from June 25th to July 25th, 2015.We evaluated in maternal registry for proper completion of partogram, the patient chart and newborn data. We looked for: uterine rupture, changing the delivery type, returning to the operating room during hospitalization or after discharge, instrumental delivery, complications in the postpartum period, maternal death. In the newborn chart we collected information on neonatal trauma due to childbirth; research proper fetal vitality; Apgar score less than 7, and death of newborns weighing more than 2,500 g, and mother / newborn (NB). For both we looked for the detection of failure to follow the clinical protocol and blood components transfusion. We also evaluated whether these components of the check list were related to incidents or EAs in health care assistance. The total number of patients studied in the period was 249 patients, and we detected 97 AEs (38.9%). Of EAs, 27 (27.8%) were detected by traditional trigger points and 70 (72.8%) extended check list. The Apgar score less than 7 at the fifth minute was detected in 11 (11.3%) of all EAs and seven newborns (7.2% of events) had some type of trauma due to childbirth, 4 NB (4, 1%) were admitted to the ICU with less than 24 hours of birth. It was noted that two patients (2%) had to undergo to further surgery and one of them is still in outpatient treatment in the unit. Two patients (2%) had lacerations third / fourth degree and one patient (1%) uterine rupture diagnosed at the time of cesarean section. In the extended check list we detected failure in medicines in 20.6% of all AEs. In this study we observed a high incidence of clinical protocols violation (39.2%). Nine patients (9.3%) had complications in the postpartum period, two (2.1%) required liaison and one patient (1%) anesthetic complications.