Author Of 1 Presentation
CRITICAL INCIDENTS: THE REALITY OF A PEDIATRIC INTENSIVE CARE UNIT IN
THE LAST TEN YEARS
Abstract
Background
A critical incident (CI) is an event or circumstance that caused or could have caused (such as a near miss) unplanned harm, suffering or loss to a patient. The study of CIs in intensive care units (ICU) is crucial to improve healthcare quality.
Objectives
To determine the incidence, type and outcomes of CI in a level III Pediatric ICU over a ten-year period (2008-2018).
Methods
Descriptive and quantitative study. Retrospective review of all CI notification forms (filled voluntarily and anonymously). Statistical analysis using SPSS® (v21, p<0,05).
Results
A total of 968 CIs were reported (34-147 per year). The main categories were: 41,7% medication (50,7% in prescription; 27,7% in administration); 17,5% airway/ventilation (64,3% in security - 88,9% of these related to accidental extubation); 12,7% procedures/techniques. The majority (64%) of CIs affected the patient and 16% of these resulted in harm. In 80% of cases, the occupation rate of ICU was equal to or above 50% and 25% occurred during the night shift. The CIs concerning ventilation were associated with greater severity, recurrence and harm to the patient (p<0,05). A higher occupation rate was also associated with greater severity (p<0,05). A total of 132 clinical recommendations were written and implemented in order to minimize the occurrence of CI.
Conclusion
CI related to medication and ventilation were the most prevalent, in line with the published literature. Notification, analysis and periodic discussion of CI are very important in order to prevent recurrence of these events.