Learning from mistakes

analyzing incidents in a neonatal care unit

Authors

  • Louíse Viecili Hoffmeister Hospital Moinhos de Vento https://orcid.org/0000-0002-8858-5693
  • Gisela Maria Schebella Souto de Moura Universidade Federal do Rio Grande do Sul, Escola de Enfermagem
  • Ana Paula Morais de Carvalho Macedo Universidade do Minho, Escola Superior de Enfermagem

DOI:

https://doi.org/10.1590/1518-8345.2795.3121

Keywords:

Patient Safety, Medical Errors, Neonatology, Nursing Care, Medication Errors, Quality of Health Care

Abstract

Objective: to analyze incidents reported in a neonatal care unit. Method: a quantitative, crosssectional and retrospective study with a sample of 34 newborns. Data were collected through a structured form, composed of two parts: sociodemographic/clinical characteristics of the newborns, and characteristics of the reported incidents. Data were collected from the institution’s computer system, in a period corresponding to 13 months, and analyzed by means of descriptive statistics. Results: the majority of the newborns were preterm (70.6%), male (52.9%) and born through caesarean section (76.5%). During the study period, 54 incidents were reported, totaling a frequency of 1.6 incident per newborn. It was found that 61.1% of incidents were related to medicines, 14.8% to accidental loss of tracheal tube and 9.3% to catheter obstruction. Conclusion: analysis of the reported incidents has shown that most incidents refer to the drug process. Information about the incidents can increase the perception of health professionals regarding the impact of their actions.

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Published

2019-03-19

Issue

Vol. 27 (2019)

Section

Original Articles

License

RLAE’s authorship concept is based on the substantial contribution by each of the individuals listed as authors, mainly in terms of conceiving and planning the research project, collecting or analyzing and interpreting data, writing and critical review. Indication of authors’ names under the article title is limited to six. If more, authors are listed on the online submission form under Acknowledgements. The possibility of including more than six authors will only be examined on multicenter studies, considering the explanations presented by the authors.
Including names of authors whose contribution does not fit into the above criteria cannot be justified. Those names can be included in the Acknowledgements section.
 Authors are fully responsible for the concepts disseminated in their manuscripts, which do not necessarily reflect the editors’ and editorial board’s opinion.

 

How to Cite

Learning from mistakes: analyzing incidents in a neonatal care unit. (2019). Revista Latino-Americana De Enfermagem, 27(e3181), e3121. https://doi.org/10.1590/1518-8345.2795.3121