Caracterização e avaliação do impacto dos erros nos serviços de medicina transfusional
Miniatura indisponível
Data
2014
Autores
Título da revista
ISSN da revista
Título do Volume
Editora
Resumo
A Medicina Transfusional não é isenta de riscos e a maioria das reacções transfusionais fatais é atribuída ao erro humano.
Neste estudo pretende-se avaliar quantitativa e qualitativamente os eventos adversos resultantes de erros, notificados pelos SMT entre 2009 e 2012; e verificar se existem diferenças entre as instituições que dispõem e as que não dispõem de CTH.
Foram analisadas as fichas de notificação de quase-erros, erros e RAR reportadas ao SPHv; os Relatórios de Actividades dos SS e SMT; e um questionário que foi enviado para todos os SMT que compunham a amostra.
Apesar da maioria dos erros não terem provocado consequências para o doente, houve erros que desencadearam RAR, nomeadamente por grupo ABO errado. As áreas clínicas quando comparadas com as laboratoriais corresponderam às áreas mais críticas. O local de transfusão (à cabeceira do doente) foi o local onde ocorreram a maioria dos erros e o laboratório de estudos pré-transfusionais onde a maioria foi detectada. Os erros com a identificação do doente e da amostra são os mais recorrentes. Os SMT cuja instituição dispõe de CTH são os que mais notificam, sendo que esta tendência é mais acentuada no que respeita aos quase-erros.
The transfusion medicine is not without risk, and most fatal transfusion reactions are attributed to human error. This study aims to assess qualitatively and quantitatively the adverse events resulting from errors reported by HBB between 2009 and 2012, and check if there are differences among the institutions that have and those that do not have the THC. The analysis focused on notification forms of near-misses, incidents and ATR reported to SPHv, the Activity Reports of BE and HBB, and a questionnaire that was sent to all HBB that comprised the sample. Although most of the errors did not cause consequences for the patient, there were errors that led to ATR, particularly for wrong ABO group. The clinical areas when compared with laboratory corresponded to the most critical areas. Local transfusion (at the bedside) was where most errors occur, and pre –transfusion studies laboratory was where the majority was detected. The patient and sample identification are the most recurrent errors. The HBB whose institution has THC are the ones that notify more, and this trend is more pronounced with respect to near- misses.
The transfusion medicine is not without risk, and most fatal transfusion reactions are attributed to human error. This study aims to assess qualitatively and quantitatively the adverse events resulting from errors reported by HBB between 2009 and 2012, and check if there are differences among the institutions that have and those that do not have the THC. The analysis focused on notification forms of near-misses, incidents and ATR reported to SPHv, the Activity Reports of BE and HBB, and a questionnaire that was sent to all HBB that comprised the sample. Although most of the errors did not cause consequences for the patient, there were errors that led to ATR, particularly for wrong ABO group. The clinical areas when compared with laboratory corresponded to the most critical areas. Local transfusion (at the bedside) was where most errors occur, and pre –transfusion studies laboratory was where the majority was detected. The patient and sample identification are the most recurrent errors. The HBB whose institution has THC are the ones that notify more, and this trend is more pronounced with respect to near- misses.
Descrição
Orientação: Vasco Reis; co-orientação: Paulo Sousa
Palavras-chave
GESTÃO DE UNIDADES DE SAÚDE, MEDICINA, TRANSFUSÕES SANGUÍNEAS, SAÚDE, DOENTES, GESTÃO DE RISCO, NEGLIGÊNCIA MÉDICA, HEALTH UNITS MANAGEMENT, MEDICINE, BLOOD TRANSFUSIONS, HEALTH, PATIENTS, RISK MANAGEMENT, MEDICAL NEGLIGENCE, MESTRADO EM GESTÃO DE UNIDADES DE SAÚDE, GESTÃO DE UNIDADES DE SAÚDE, HEALTH UNITS MANAGEMENT