SAFETY AND PROTECTI ON FOR HOSPI TALI ZED CHI LDREN: LI TERATURE REVI EW
Aline Modelski Schat koski1
Wiliam Wegner2 Sim one Algeri3
Eva Neri Rubim Pedro4
Schat kosk i AM, Wegner W, Alger i S, Pedr o ENR. Safet y and pr ot ect ion for hospit alized childr en: lit erat ur e review. Rev Lat ino- am Enferm agem 2009 m aio- j unho; 17( 3) : 410- 6.
This narrative- descriptive review is about the safety/ protection of hospitalized children who, due to their fragility, vulnerabilit y and peculiar growt h and developm ent condit ions need special at t ent ion from healt h professionals. This st udy aim ed t o ident ify knowledge product ion on safet y, prot ect ion and violence t o hospit alized children bet ween 1997 and 2007. I n t ot al, 15 nat ional and int ernat ional art icles were analyzed, using t he key words: hospit alized child, safet y, violence and nur sing. This qualit at ive appr oach enabled t he developm ent of four cat egories: adverse occurrences; m edicat ion errors; not ificat ion of adverse occurrences; and safet y of pediat ric pat ient s. Result s indicat e t he need t o develop st rat egies t o reduce t he probabilit y of t hese event s occurring during children’s hospit alizat ion, so t hat t hey do not suffer any problem neit her violat ion of t heir fundam ent al r ight s.
DESCRI PTORS: child, hospit alized; safet y; violence; nursing
SEGURI DAD Y PROTECCI ÓN PARA EL NI ÑO HOSPI TALI ZADO: ESTUDI O DE REVI SI ÓN
El est udio t r at a de la segur idad y pr ot ección del niño hospit alizado que, por su fr agilidad, vulner abilidad y condiciones peculiares de crecim ient o y desarrollo, necesit a at ención especial de los profesionales de la salud. Es una revisión narrativa y descriptiva que tuvo por obj etivo identificar la producción de conocim iento sobre el tem a de la seguridad y protección del niño hospitalizado, en el período com prendido entre 1997 y 2007. Fueron analizados 15 artículos, nacionales e internacionales utilizando las palabras clave: niños hospitalizados; seguridad; violencia y enferm ería. El abordaj e cualitativo perm itió la form ulación de cuatro categorías: ocurrencias adversas; errores de m edicación; not ificación de event os adversos; y, seguridad del pacient e pediát rico. Los result ados apuntan la necesidad de desarrollar estrategias que reduzcan la probabilidad de la ocurrencia de estos eventos, d u r an t e la h osp it alización d el n iñ o, p ar a q u e él n o su f r a cu alq u ier d añ o n i v iolación d e su s d er ech os fundam ent ales.
DESCRI PTORES: niño hospit alizado; seguridad; violencia; enferm ería
SEGURANÇA E PROTEÇÃO À CRI ANÇA HOSPI TALI ZADA: REVI SÃO DE LI TERATURA
O est udo t rat a da segurança/ prot eção da criança hospit alizada que, devido à sua fragilidade, vulnerabilidade e condições peculiares de crescim ent o e desenvolvim ent o, necessit a de at enção especial dos profissionais de saúde. É um a revisão narrativo- descritiva que obj etiva identificar a produção do conhecim ento sobre a tem ática da segurança, prot eção e violência à criança hospit alizada, no período de 1997 a 2007. Foram analisados 15 art igos, nacionais e int ernacionais, ut ilizando- se as palavras- chave: criança hospit alizada, segurança, violência e enferm agem . A abordagem qualit at iva possibilit ou a form ulação de quat ro cat egorias na análise: ocorrências adv er sas, er r os de m edicação, not ificação de ocor r ências adv er sas e segur ança do pacient e pediát r ico. Os result ados indicam a necessidade de se desenvolver est rat égias que reduzam a probabilidade da ocorrência desses ev ent os, dur ant e a hospit alização da cr iança, par a que ela não sofr a qualquer int er cor r ência nem violação de seus direit os fundam ent ais.
DESCRI TORES: criança hospit alizada; segurança; violência; enferm agem
1RN, e- m ail: alinem odelski@gm ail.com ; 2RN, Doct oral St udent in Nursing, Escola de Enferm agem , Universidade Federal do Rio Grande do Sul, Brazil, Full
Professor, Cent ro Universit ário Met odist a I PA, e- m ail: wiliam .wegner@m et odist adosul.edu.br; 3RN, Ph.D. in Educat ion, Adj unct Professor, Escola de
Enferm agem da Universidade Federal do Rio Grande do Sul, Brazil, e- m ail: [email protected] .br; 4RN, Ph.D. in Educat ion, Facult y, Escola de Enferm agem
da Universidade Federal do Rio Grande do Sul, Brazil, e- m ail: [email protected] .br.
I NTRODUCTI ON
C
hildr en and t heir com panions’ pr ot ect ion and safet y, and t heir im plicat ions for healt h, hav e d r i v e n r e se a r ch a n d e n a b l e d d i scu ssi o n o n t h e q u alit y of h ealt h car e. Nev er t h eless, f ew st u d ies a d d r e ssi n g t h e su b j e ct a n d p r o b l e m a t i zi n g t h e count less int er faces of healt h car e user s’ pr ot ect ion and safet y w er e found( 1- 3).This t hem e shar pens focus on t he subj ect of inst it ut ional v iolence per pet r at ed in healt h car e ser v ices, w hich is lit t le discussed or cont ex t ualized b e c a u s e i t i s a d i f f i c u l t t o p i c t o a d d r e s s a n d , som et im es, n ot p er ceiv ed b y m ost p r of ession als and ev en user s. Sev er al act or s ar e inv olv ed in t his cont ex t ( nur sing, m edical and social w or k er t eam s, am ong ot her s) , in differ ent sit uat ions ( unnecessar y m ech an ical sp lin t s, p r escr ip t ion er r or s, er r or s in m ed icat ion ad m in ist r at ion , in cor r ect ex am in at ion r e q u e st s, p r o l o n g e d f a st i n g a n d n o n - sch e d u l e d su r g i ca l p r o ced u r es, b u r ea u cr a t i c p r o ced u r es i n ca r e , i n f l e x i b i l i t y r e g a r d i n g co m p a n i o n s, v e r b a l a g g r e s s i o n , m i s i n f o r m a t i o n , e t c . ) , w h i c h a r e t h em sel v es u n p r ed i ct ab l e. Th e u ser s of ser v i ces ar e ex posed t o r isk s, er r or s, adv er se ev en t s an d/ or acciden t s du r in g h ealt h car e.
Healt h en v ir on m en t s ar e ch ar act er ized by m acr o com p l ex i t i es, r el at ed t o t ech n ol og i es an d m u l t i p r o f e s i o n a l t e a m s w o r k i n g i n t h e s e en v ir on m en t s, w it h p ar t icu lar m an if est at ion s. We f r e q u e n t l y o b s e r v e h e a l t h p r o f e s s i o n a l s u s i n g p ow er an d d om in at ion r elat ion s t h at ch ar act er ize t h eir p r ax is in r elat ion t o ser v ice u ser s, w h et h er at h ospit als, h ealt h u n it s, em er gen cy ser v ices, or ot her s. This st udy focuses on t he hospit al cont ex t and, t hus, it is im por t ant t o pr oblem at ize t he t hem e an d con t ex t u alize it t o policies h u m an izin g h ealt h car e and pr ot ect ion( 4- 6). Healt h pr ofessionals should
be concer ned t o ensur e childr en’s and adolescent s’ r i g h t s a n d co m m i t t h e m se l v e s t o p r o m o t i n g a p o p u l a t i o n ’ s h ea l t h , a cco r d i n g t o t h e Ch i l d a n d Adolescen t St at u t e ( ECA)( 6 ).
Ar ound 3 t o 4% of hospit alized pat ient s ar e im pair ed by car e act ions t hat ar e supposed t o help t h em . I t is est im at ed t h at ap p r ox im at ely 4 4 an d 9 8 t h o u s a n d A m e r i c a n s d i e e v e r y y e a r a s c o n s e q u e n c e o f e r r o r s i n h e a t h c a r e . H e a l t h ser v ices sh ou ld b e q u alif ied t o p r ev en t er r or s( 5 ).
Th e l i t e r a t u r e d o e s n o t p r o v i d e st a t i st i cs t h a t
cont ex t ualize t he Brazilian r ealit y, w hich highlight s t he im por t ance of r esear ch addr essing t his t hem e. I nst it ut ional v iolence is under st ood as t hat p r act iced in or b y p u b lic ser v ices t h em selv es b y act ion or om ission, and is also com pr ised of abuses com m it t ed due t o unequal pow er r elat ions bet w een u s e r s a n d p r o f e s s i o n a l s i n s i d e i n s t i t u t i o n s( 7 ).
Pr o t e c t i o n o f c h i l d r e n i s u n d e r s t o o d a s t h e g u a r a n t e e o f t h e f u n d a m e n t a l r i g h t s a n d l e g a l disposit ion s est ablish ed by ECA( 6 ).
A u t h o r s ’ p r o f e s s i o n a l e x p e r i e n c e a s p e d i a t r i c n u r s e s , e n a b l e d t h e v i s u a l i z a t i o n o f s e v e r a l s i t u a t i o n s r e l a t e d t o v i o l e n c e , r i s k , v u l n er ab i l i t y, saf et y an d p r o t ect i o n i n a co n t ex t opposed t o t he hum anizat ion of hospit al car e. This st u d y a i m e d t o i d e n t i f y d i sco v e r i e s co n ce r n i n g sa f e t y, p r o t e ct i o n a n d v i o l e n ce t o h o sp i t a l i ze d childr en bet w een 1 9 9 7 and 2 0 0 7 .
METHOD
Th i s i s a d e s c r i p t i v e n a r r a t i v e r e v i e w , t r a d i t i o n a l l y k n o w n a s a l i t e r a t u r e r e v i e w( 8 ).
Sou r ces u sed in t h is st u dy w er e scien t ific ar t icles pu blish ed bet w een 1 9 9 7 an d 2 0 0 7 . Th e f ollow in g quest ion guided t he ar t icles sear ch: w hat has t he n a t i o n a l a n d i n t e r n a t i o n a l s c i e n t i f i c l i t e r a t u r e p r e se n t e d o n sa f e t y / p r o t e ct i o n o f h o sp i t a l i z e d ch ildr en ? Sou r ces w er e select ed t h r ou gh sear ch es in elect r on ic dat abases of t h e Libr ar y Au t om at ion Sy st em of t he College of Nur sing of t he Rio Gr ande d o Su l Fed er al Un i v er si t y ( BD ENF) , i n t h e Lat i n A m e r i c a n a n d Ca r i b b e a n Ce n t e r o n H e a l t h Scien ces I n f or m at ion Sy st em ( LI LACS) , Nat ion al Libr ar y of Medicine ( MEDLI NE) , Scient ific Elect r onic Libr ar y On lin e ( SCI ELO) an d Cu m u lat iv e I n dex t o Nur sing and Allied Healt h Lit er at ur e ( CI NAHL) . The follow ing descr ipt or s w er e used: hospit alized child, saf et y, v iolen ce an d n u r sin g.
I n f o r m a t i o n a n a l y s i s w a s d o n e b y a n ex p lor at or y r ead in g of t h e b ib liog r ap h ic m at er ial found using a qualit at iv e appr oach. Reading of t he ar t icles r ev ealed cent r al conv er gences, w hich w er e sy n t h esized, gr ou ped an d cat egor ized. Cat egor ies w e r e : a d v e r se o ccu r r e n ce s, m e d i ca t i o n e r r o r s, n ot if icat ion of ad v er se occu r r en ces an d saf et y of pediat ric pat ient s.
e l t i
T Author Year
.
1 NurseStafifngandAdverseEventsinHosptiailzedChlidren Mark,B.A;.Halress,D.W;.Berman,W.F. 2007
.
2 MedicaitonSafetyinCiritcallyIllChlidren Lesa,rT.S;.Mtichel,lA;.Sommo,P. 2006
.
3 FallsinHosptiailzedChlidren Razmus,.Ieta.l 2006
.
4 BasicConceptsinPediatircPaitentSafety:AcitonsTowardaSaferHeatlh m
e t s y S e r a
C Napie,rJ.Knox,E.
6 0 0 2
.
5 AdverseEventsandPreventableAdverseEventsinChlidren Woods,D.eta.l 2005
.
6 ReporitngofMedicaitonErrorsbyPediatircNurses Stratton,K.M.Eta.l 2004
.
7 PediatircPaitentSafetyinHosptials:aNaitonalPicturein2000 Mille,rM.R;.ZhanC. 2004
.
8 StrategiesforthePrevenitonofMedicalErrorinPediatircs Fernandez,C.V;.Gliils-Ring,J. 2003
.
9 PaitentsSafetyEventsduirngPediatircHosptiailzaitons Mille,rM.R;.Eilxhause,rA;.Zhan,C. 2003
. 0
1 UOncoidrarêdnecdiaesCAudivdeardsoassIenteCnosnisvoesquPêendciiáatsircImoesd.iatasparaosPacientesem Harada,M.J.CS;.Mairn,H.F;.Carvalho,W.B. 2003
. 1
1 Hosptia-lReportedMedicalErrorsinChlidren Slonim,D.eta.l 2003
. 2
1 PirnciplesofPaitentSafetyinPediatircs AmeircanAcademyofPediatircs 2001
. 3
1 MedicaitonErrorsandAdverseDrugEventsinPediatircInpaitents Kausha,lR.eta.l 2001
. 4
1 MedicalErrorReporitng:ASurveyofNursingStaff Antonow,J.A;.Smtih,A.B;.Slive,rM.P. 2000
. 5
1 AViolênciaàCirançaHosptiailzada:aDimensãoÉitcadaIntervenção a
c it u ê p a r e
T Ribeiro,R.L.R;.Ramos,F.R.S.
9 9 9 1
RESULTS
Table 1 show s t he r esult s of t he dat abase sea r ch , l i st i n g t h e t i t l es, a u t h o r s a n d d a t es f o r subsequent analysis. All art icles were fully read and on ly t h e on es in clu din g aspect s r elat ed t o saf et y, violence and prot ect ion of hospit alized children were select ed.
Table 1 – List of articles found in the research
DI SCUSSI ON
Hospit alized children are m ore vulnerable t o v iolent act ions, need closer super v ision and cannot d eci d e a b o u t t h ei r o w n ca r e( 1 ). Th ey ca n su f f er
different form s of inst it ut ional violence, which, m any t i m e s, a r e i g n o r e d a n d u n n o t i ce d b y h e a l t h pr of ession als. Ov er t im e, t h ese f or m s of v iolen ce becom e invisible both to the ones directly responsible for car e as m anager s and ot her pr ofessionals. The cat eg o r i es t h at em er g ed f r o m d at a an al y si s ar e pr esent ed next .
Adv er se occur r ences
An ad v er se occu r r en ce is an u n d esir ab le event, harm ful or not, to the patient and which occurs
during t he provision of healt h care in consequence, or not , of t he failure of t he professional responsible for care, and m ay com prom ise pat ient safet y( 9- 10).
A study carried out with 3,719 patients from 0 t o 20 years of age in U.S. hospit als show ed t hat a d v e r se e v e n t s o ccu r i n 1 % o f p e d i a t r i c h o sp i t a l i za t i o n s a n d t h a t 0 . 6 % o f t h e m a r e p r ev en t ab l e. Ad o l escen t s ( f r o m 1 3 t o 2 0 y ear s) su f f er ed t h e h i g h est n u m b er o f a d v er se ev en t s ( 3.41% ) ; 78% of t he adverse event s occurred wit h newborns, 10.8% in children at school age ( 1 t o 12 y e a r s) a n d 7 8 . 6 % o f t h e a d v e r se e v e n t s w i t h adolescent s were prevent able( 11).
f a ct o r s, b a se d o n t h e p a t i e n t sa f e t y i n d i ca t o r dev eloped by t h e Agen cy for Healt h car e Resear ch and Qualit y. I t showed t hat t he m ain adverse event s w er e t hose r elat ed t o obst et r ic t r aum as, or vaginal b i r t h u si n g i n st r u m en t s, ( 2 1 . 5 2 % ) , f o l l o w ed b y ob st et r ic t r au m as w it h ou t in st r u m en t s ( 1 0 . 7 2 % ) , r escu e f ailu r es ( 7 . 0 3 % ) an d p ost op er at iv e sep sis ( 1 . 0 3 % )( 1 2 ). A sim ilar st u d y, cov er in g 3 . 8 m illion
children and adolescent s, showed analogous result s, also point ing out t he higher occur r ence of adv er se ev en t s r elat ed t o t r au m as in n ew b or n s ( 1 . 5 4 % ) , p o st o p e r a t i v e i n f e ct i o n s ( 0 . 4 4 % ) a n d o b st e t r i c co m p l i ca t i o n s ( 0 . 2 6 % )( 1 3 ). Th e se a n a l y se s
d em on st r at e t h at ev en t s ar e sim ilar an d can b e prevent ed, however, furt her research is needed.
Docum ent analysis of the U.S. health system show ed t hat bet w een 1988- 1997, t he incidence of m edical er r or s in pediat r ic pat ient s incr eased fr om 1.81% to 2.96%(14). A nursing study carried out in Brazil
in the pediatric intensive care unit of a school hospital in São Paulo present ed 2.9 adverse occurrences per child as a result of nursing care practice. This research identified events related to m edication (32.7% ) as the m ost fr equent , follow ed by m echanical v ent ilat ion/ a i r w a y s ( 2 9 . 2 % ) , n u r si n g p r o ce d u r e s ( 1 6 . 8 % ) , cat het ers, probes and dr ains ( 14.3% ) , equipm ent s/ m aterials (4.4% ) and others (2.6% )(10).
Falls in the hospital environm ent are another type of com m on problem in the context of user safety. A st udy t hat analyzed files of 200 pat ient s who had fell in a hospit al in t he Unit ed St at es ident ified t hat 82% of children were with parents during falls( 15). Falls
can be relat ed t o insecurit y and apprehension wit hin p ar en t s in sid e t h e h osp it al en v ir on m en t , b esid es cir cum st ances associat ed t o w or k er s’ daily pr act ice and issues relat ed t o healt h care inst it ut ions.
The environm ent and the organization of work in hospital can cause violence, since carelessness and w o r k e r s’ l a ck o f m o t i v a t i o n a r e v i si b l e t h r o u g h ca r e l e ss h y g i e n e , i n a t t e n t i v e n e ss i n t h e w o r k en v i r o n m en t an d i n f o l l o w i n g a r o u t i n e an d t h e prevalence of adult - cent ered t echnologies( 16). Fact ors
relat ed t o t he organizat ion of work, very com m on in daily nur sing pr act ice, can also t r igger er r or s: t he accum ulat ion of act ivit ies, inadequat ely t rained and in su f f icien t per son n el, lack of m at er ial r esou r ces, in t er r u p t ion b y colleag u es d u r in g p r oced u r es an d envir onm ent al condit ions, such as poor illum inat ion and presence of noise, m ake children m ore vulnerable t o adverse event s.
Of t he adv er se ev ent s, 34. 2% occur r ed in obstetric services, 18% in surgical services and 14.5% in pediatrics( 11). The em ergency sector m ost lent itself
t o t h e o ccu r r en ce o f er r o r s. I n t en si v e car e an d oncology services, due to the com plexity of care, were also places likely t o present errors( 17).
The type and incidence of errors are related. Boys had higher rat es of m edical errors in all years. An ot h er aspect r ev ealed is t h at m ost occu r r en ces happened to children between 6 and 12 years of age in all years of study( 14). I n the case of boys, the cultural
ex pect at ions at t his age t o “ act like a m an”, or be courageous and st rong, are very deep, leading t hem t o r eact t o st r ess w it h st oicism , isolat ion, passiv e accept ance or host ilit y, rage and aggr essiveness( 18).
Th ese beh av ior s can t r igger n egat iv e at t it u des in healt h pr ofessionals, st im ulat ing t he occur r ence of ad v er se ev en t s su ch as in ap p r op r iat e m ech an ical r est r ain t , v er bal aggr ession , in cor r ect pr ocedu r es a n d e v e n i n a p p r o p r i a t e a d m i n i s t r a t i o n o f m ed icat ion .
Younger children ( under one year old) suffer t he highest num ber of adv er se ev ent s( 12). Childr en
u n d er on e y ear of ag e con t r ol t h eir en v ir on m en t t h r ou gh em ot ion al ex pr ession s, su ch as cr y in g or sm iling or m anual explorat ion t hrough t ouch( 18).
These issues ar e pr esent ed as r isk fact or s for adverse event s. Adverse event s are significant ly associated with the increase in length of hospitalization, cost s and m ort alit y during hospit alizat ion( 12- 13). Thus,
sp ecif ic act ion s ar e su g g est ed f or each st ag e of developm ent and adapt at ions according t o t he needs of each child insert ed int o a care environm ent .
Medicat ion er r or s
Of t he 15 ar t icles found, four addr ess only m edicat ion errors, defined as errors in prescript ion, i n t e r p r e t a t i o n , d i sp e n si n g , a d m i n i st r a t i o n o r m onit or ing of m edicine. Adver se r eact ions t o dr ugs are harm s caused by the use of som e m edication( 19).
Ch ild r en ar e m or e v u ln er ab le d u e t o t h e gr eat er v ar iat ion of t heir w eight , w hich m ak es t he calcu lat ion of t h e d osag e m or e d if f icu lt , p r esen t v ar iat ions in t he lev el of phy siological m at ur at ion, difficult ies in pat ient ident ificat ion, lim it ed abilit y t o com m unicat e, higher probabilit y of overdoses or low doses( 20). New borns suffered t he highest num ber of
A st u d y e x a m i n i n g a d v e r se o ccu r r e n ce s involving m edicat ion errors as t he m ain undesirable cause of nur sing m alpr act ice, due t o alt er at ions in m et abolism and excret ion of drugs, shows t he need t o d iv id e m ed icat ion in t o sev er al d oses, b esid es adj ust ing t hem t o child’s weight( 10). The frequency of
a d v e r se r e a ct i o n s i s r e l a t e d t o t h e n u m b e r o f m edicat ions used, sev er it y of pat ient s’ disease and care acuit y( 20).
Re g a r d i n g t h e t y p e o f m e d i ca t i o n e r r o r, dosage errors were the m ost frequent ( 28% ) , followed by errors in adm inist rat ion rout es ( 18% ) and errors in r ecor ding adm inist r at ions ( 14% ) . Concer ning t he st age at which error occurs, m ost are at prescript ion ( 74% ) and adm inist rat ion errors are around 10%( 19).
Th er e is r isk of er r or in dosage calcu lat ion , sin ce children are changing physically and physiologically. There is also the possibility of error due to inadequate k now ledge of phar m acok inet ics, phar m acody nam ics an d t h e t o x i ci t y o f so m e d r u g s ad m i n i st er ed t o children( 17).
D o sa g e e r r o r s a r e t h e m o st co m m o n , especially in cases of ov er dose( 20). The r easons for
m edicat ion er r or s ar e dist r act ions and int er r upt ions ( 5 0 % ) , d o se f r a ct i o n a t i o n ( 3 7 % ) a n d v a r i o u s i n co m p a t i b l e m e d i ca t i o n s t o t h e sa m e p a t i e n t ( 35% )( 21).
St u d i e s sh o w t h a t 5 . 7 % o f m e d i ca t i o n prescriptions present errors and 0.24% show adverse effect s t o drugs, of which 19% were prevent able( 19).
Ad v er se occu r r en ces w it h m ed icat ion can lead t o i n cr e a se s i n t r e a t m e n t co st s a n d l e n g t h o f h osp it alizat ion , cau sin g ser iou s con seq u en ces t o pat ient s’ healt h. I t can affect childr en’s safet y and t he qualit y of care delivered( 10).
Th u s, a per t in en t qu est ion is h ow n u r sin g pr ofessionals’ educat ion addr esses t his aspect and en cou r ages t h e sear ch f or im pr ov ed an d u pdat ed knowledge, so that they are able to critically interpret pr escr ipt ions.
Not ificat ion of adverse occurrences
The true frequency in which m edication errors occur is not act ually known, due t o t he difficult y in identifying and quantifying the problem . The frequency in com m unicat ion of errors varies considerably, due t o t he m et hods used, definit ion of adverse react ion and/ or error and care environm ent( 20).
Com m unicat ion of t he occurrence of adverse e v e n t s i s v e r y i m p o r t a n t b e ca u se i t a l l o w s t h e m easures necessary t o revert such event s be rapidly t aken. A new cult ure should be est ablished in healt h services with a view to learn from errors and not only sear ch for t he guilt y. The cr it ical and inv est igat iv e p e r sp e ct i v e o f e r r o r s i n h e a l t h se r v i ce s sh o u l d super sede t he punit iv e im pulse. These need t o be studied and solved, aim ing to favor users and all those involved in t he healt h care process( 9).
Anot her survey show ed t hat st udied nurses estim ated that 67% of m edication errors that occurred in t heir unit s w er e pr oper ly com m unicat ed( 21). I t is
w or t h r eflect in g on t h e Br azilian r ealit y. Does t h e culture of com m unicating errors exist? How does one discuss the im portance of users’ safety and protection in v iew of possibilit ies of er r or s and/ or har m s w it h t he healt h t eam ?
The follow ing m ot ives w er e am ong r easons not ed not t o report adverse occurrences: nursing is m or e f ocu sed on p eop le t h an on t h e sy st em an d nur ses ar e afr aid of t he consequences t hey w ould suffer in com m unicat ing er r or s( 2 2 ). This is anot her
a sp e ct t h a t d e se r v e s a t t e n t i o n . W h a t a r e t h e con seq u en ces f or w or k er s in case t h ey r ep or t an error? What does the law provide? How do users and/ or relatives cope with this situation in the event they are inform ed? What support network do workers have t o f acilit at e com m u n icat ion ? I s t h er e a collect iv e a w a r e n e ss o f w o r k e r s, m a n a g e r s a n d o f t h e adm inist rat ive body t hat dam ages t o pat ient s should be r epor t ed, st u died, pr ev en t ed? Th ese qu est ion s could be discussed am ong people involved in the safety and prot ect ion of healt h services users.
A study evidenced that 53% of the m edication e r r o r s o ccu r r e d i n t h e p r e scr i p t i o n , 3 7 % w e r e int er pr et at ion er r or s, 4 4 % dispensing er r or s, 4 3 % ad m in ist r at ion er r or s, an d 3 0 . 5 % of all ob ser v ed errors were form ally com m unicat ed. The errors m ost f r eq u en t ly f or m ally com m u n icat ed w er e t h e on es r e g a r d i n g a d m i n i st r a t i o n ( 5 1 % ) , f o l l o w e d b y int erpret at ion ( 24% ) and prescript ion ( 16% )( 23).
Safet y of pediat ric pat ient s
Patient safety is defined as the prevention of errors in health care and the reduction of the repercussions from errors in patients’ lives and health. Patient safety is influenced by t he work environm ent , and form ed by involved workers, workers’ individual and collective issues and institutional aspects, among others(7).
Concern for pat ient safet y is recent and has global dim ensions. This can be observed t hrough t he World Healt h Organizat ion and t he World Alliance for Patient Safety, as well as other organizations that were created with this concern, such as the National Patient Safet y Foundat ion, t he Agency for Healt hcar e and Quality ( AHRQ) and the National Coordinating Council for Medicat ion Error Report ing and Prevent ion( 24).
Th er e ar e f ew p u b licat ion s r eg ar d in g t h e saf et y of pediat r ic pat ien t s, an d u su ally t h ey ar e based on st r at egies alr eady obser v ed w it h pat ient s in general. All levels of healt h should be concerned t o prevent errors. The first st ep is t o ident ify errors and st udy t heir occur r ence pat t er ns t o r educe t he p r o b a b i l i t y o f o ccu r r e n ce o f a d v e r se e v e n t s( 5 ).
I n div idu al su r v eillan ce, alt h ou gh n ecessar y, is n ot enough t o develop safe care for children. St rat egies should support t he organizat ional process t o im prove t he qualit y, safet y and healt h in pediat r ics( 24). The
m ain aspect s for safet y in t he healt h syst em should be: leadership, inform at ion syst em s and not ificat ion of errors, change of behavior pat t erns, increase and/ or reinforce fam ily and pat ient involvem ent( 20- 24).
Pat ient safet y should be t he pr ior it y, t hus, t h er e sh ou ld b e on g oin g ed u cat ion p r og r am s f or professionals regarding t his issue. The not ificat ion of errors should be non- punitive and confidential, so that t here can be significant learning from it s occurrence, enabling crit ical reflect ion of t he errors present ed.
I n 2001, a guidebook was published by t he Am erican Academ y of Pediat rics t o prom ot e safet y in the health system , whose recom m endations are: build a sy st em of er r or s not ificat ion; dev elop guides for hospitals by m ultidisciplinary team s to prom ote patient safety, with special attention to pediatric patients, and the creation of a patient safety program that prom otes collect ive com m it m ent t o safet y( 5).
Focus on patient safety and the quality of care, wit h consequent developm ent of a cult ure of safet y, enable the team to feel safe when reporting an adverse event( 22).
FI NAL CONSI DERATI ONS
Th is st u d y p er m it t ed v er if y in g t h at t h er e is an incipient Br azilian pr oduct ion of r esear ch on s a f e t y a n d p r o t e c t i o n o f c h i l d r e n i n h o s p i t a l env ir onm ent s, w it h t w o ar t icles found in t he st udied per iod. On t he ot her hand, t his st udy dem onst r at ed i n t er n at i on al m ob i l i zat i on i n f av or of saf et y an d pr ot ect ion of hospit alized childr en, especially in t he Un i t ed St at es. Recen t co n cer n w i t h t h i s t h em e, f ocu sed on adu lt h ealt h , is iden t if ied in t h e Lat in Am er ican Jou r n al of Nu r sin g. Th u s, it is essen t ial t o st im u lat e t h e p r od u ct ion of st u d ies r eg ar d in g ch ild r en an d ad olescen t s.
Adv er se event s, as pr esent ed in t his st udy, a r e c o n s i d e r e d f r e q u e n t f o r m s o f i n s t i t u t i o n a l v iolence and ar e par t of daily pr act ice and can hav e light , m oder at e or sev er e consequences. The m ost r epor t ed ev ent found in t he st udies w as m edicat ion er r or, t o w hich nur sing is dir ect ly r elat ed, since it cont r ols t he last st age of t his pr ocess, t hat is, t he ad m in ist r at ion of m ed icat ion s.
Wor k er s should hav e an at t it ude st r essing t h e i m p o r t a n c e o f r e p o r t i n g e r r o r s a i m i n g t o i m p l e m e n t m e a su r e s f o r p a t i e n t s a s w e l l a s t o a v o i d n e w e r r o r s w i t h s i m i l a r c h a r a c t e r i s t i c s . How ev er, t his does not alway s occur, as oft ent im es w or k er s ar e fear ful of punishm ent and do not k now t h e r eal aim an d im por t an ce of r epor t in g er r or s.
Th e ad v er se o ccu r r en ces d escr i b ed h er e ar e f ocu sed on m edical in t er v en t ion s; h ow ev er, it i s w o r t h h i g h l i g h t i n g t h e r o l e o f n u r s i n g pr of ession als in t h is sit u at ion . Th e su per v ision of nur ses in t he t eam s’ dir ect w or k should be t he basis o f d e c i s i o n - m a k i n g , e s t a b l i s h e d o n s c i e n t i f i c k now ledge, suppor t ed by law , ensur ing t he safet y a n d p r o t e c t i o n o f c h i l d r e n a n d f a m i l i e s . T h e par t icipat ion of childr en’s fam ily in t he ident ificat ion a n d p r e v e n t i o n o f a d v e r se o ccu r r e n ce s i s a l so r ei n f o r ced .
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