Alan A. Vieira

Erro médico em pacientes hospitalizados

Objetivo: o presente artigo tem por objetivo revisar a literatura e discutir a questao do erro medico em pacientes hospitalizados, enfocando sua conceituacao, incidencia, fatores predisponentes e mecanismos de prevencao. Aborda, em especial, erros e eventos adversos com drogas envolvendo recem-nascidos e pacientes pediatricos. Metodos: revisao bibliografica utilizando banco de dados Medline, selecionando-se aqueles com informacoes atuais e relevantes. Resultados:mesmo assumindo que a notificacao do erro medico nao ocorre em um grande numero de eventos, e importante notar que sua incidencia e muito maior do que julgamos. So nos EUA, cerca de um milhao de pacientes por ano sao vitimas de erros medicos e eventos adversos com drogas. Segundo recente metanalise, esta e, hoje, a quarta causa de morte nos EUA. Em unidades de terapia intensiva neonatal e pediatrica, nas quais e grande a complexidade e a frequencia de procedimentos, a ocorrencia de erros e maior. Estima-se que quinze por cento das internacoes em unidades de terapia intensiva neonatal sejam acompanhadas de erro medico. A maioria destes erros acontece durante o periodo noturno, e envolve administracao incorreta de droga (35%) e erro na interpretacao da prescricao (26%). Fatores ambientais (barulho, calor), psicologicos (tedio, ansiedade, estresse) e fisiologicos (fadiga, sono) contribuem para a ocorrencia de erros. Recente estudo revela que apos um plantao de 24 horas, sem dormir, o desempenho psicomotor de um profissional de saude e semelhante ao de um individuo legalmente bebado (nivel serico alcoolico maior ou igual a 0,08%)! Conclusoes: mesmo em profissionais conscientes, erros sao acompanhantes inevitaveis da condicao humana. A prevencao de erros deve basear-se na busca de causas reais, que geralmente incluem erros no sistema de organizacao e implementacao do servico. Erros devem ser aceitos como evidencia de falha no sistema, e encarados como oportunidade de revisao do processo e aprimoramento da assistencia prestada ao paciente.

Medication errors in a neonatal intensive care unit

OBJECTIVE To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patients clinical status. METHODS We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months. RESULTS Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g) and mean gestational age was 34 weeks (25-40 weeks). Of 73 medical charts analyzed, 40 (55%) had one or more errors. A total of 365 days of hospitalization was analyzed and 95 medical errors were detected (one error per 3.9 days of hospitalization). The most frequent error was associated with medication use (84.2%). Use of therapeutic procedures (drugs, phototherapy, etc.) without proper prescription in the patients chart (commission error) accounted for 7.4% of the errors, and incidence of omission errors was 8.4%. Incidence of medical errors was significantly higher in newborn infants with lower gestational age. CONCLUSIONS Incidence of errors in the care of high-risk newborn infants is elevated. Strategies to improve education of health professionals involved in the care and development of local culture by disseminating clear, accessible algorithms to guide behavior when errors occur must be encouraged.

O uso da fototerapia em recém-nascidos: avaliação da prática clínica

OBJECTIVES: to describe the use of phototherapy in the day to day clinical practice by healthcare professionals of public maternity hospitals in the city of Rio de Janeiro. METHODS: heads of healthcare departments, doctors and nurses of 17 public maternity hospitals were interviewed on issues related to phototherapy management in their services. RESULTS: eighty nine healthcare professionals were interviewed. Seventy four per cent of the doctors noted there was a written guideline for neonatal jaundice management in their departments but with a great variation of responses related to the medical conduct adopted, including among professionals working in the same unit, 74% of doctors prescribed prophylactic phototherapy and 64% said they increased fluid intake during treatment. Distance placed between the newborn and the irradiance source varied from 20 to 70 cms. Half of the respondents noted the lack of guidelines to verify irradiation during phototherapy. A marked variation of bilirubin serum levels were used for phototherapy and exchange blood transfusion indications. CONCLUSIONS: our findings suggest the lack of consensus among healthcare professionals related to the use of phototherapy and that some of the routinely adopted practices could impair treatment efficacy.

Assessment of the energy content of human milk administered to very low birth weight infants

OBJECTIVE To evaluate and compare the energy content in fresh and processed human milk administered to very low birth weight infants born in the Institute Fernandes Figueira. METHODS Samples of 0.5 ml of fresh and processed human milk were evaluated as for the fat percentile and energy content, which was calculated by mathematical formulas. Four hundred and sixty two human milk samples were analyzed, 401 of processed human milk and 61 of fresh human milk. RESULTS The median and the standard deviation of the fat percentile checked was 2.9+/-1.2% in the processed samples and 8.9+/-4.6% in the fresh samples (p < 0.001). The median and the standard deviation of the energy content calculated was 53.6+/-7.2 kcal/100 ml in processed samples and 85.9+/-27.9 kcal/100 ml in fresh samples (p < 0.001). CONCLUSION The processed human milk samples had less energy content and less fat than fresh human milk samples suggesting that the complex processes of the human milk manipulation and administration can determine losses in energy content.

Implementation of a protocol proposed by the brazilian National Health Surveillance Agency for antibiotic use in very low birth weight infants

OBJECTIVE To analyze the implementation of a protocol proposed by the Brazilian National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária - ANVISA) to improve sepsis diagnosis in very low birth weight newborns. METHODS This was a prospective study that evaluated the implementation of a protocol involving clinical and laboratory criteria (hematologic scoring system of Rodwell and C-reactive protein serial measurements), recommended by ANVISA, to improve the diagnosis of neonatal sepsis in very low birth weight newborns. The study included all patients who were born and remained in the neonatal intensive care unit until discharge or death, and excluded those with congenital diseases. The main outcomes measured in newborns before (2006-2007) and after implementation of the protocol (2008) were the rates of early and late-onset sepsis, use of antibiotics, and mortality. Means were compared by Students t-test and categorical variables were compared by the chi-squared test; the significance level for all tests was set at 95%. RESULTS The study included 136 newborns with very low birth weight. There was no difference between groups regarding general clinical characteristics in the studied periods. There was, however, a decrease in the number of diagnoses of probable early-onset sepsis (p<0.001), use of antimicrobial regimens (p<0.001), and overall mortality and infection-related mortality (p=0.009 and p=0.049, respectively). CONCLUSION The implementation of the protocol allowed improvement of sepsis diagnosis by reducing the diagnosis of probable early-onset sepsis, thus promoting efficient antimicrobial use in this population.

Erros medicamentosos em unidade de terapia intensiva neonatal

OBJECTIVE: To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patients clinical status. METHODS: We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months. RESULTS: Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g) and mean gestational age was 34 weeks (25-40 weeks). Of 73 medical charts analyzed, 40 (55%) had one or more errors. A total of 365 days of hospitalization was analyzed and 95 medical errors were detected (one error per 3.9 days of hospitalization). The most frequent error was associated with medication use (84.2%). Use of therapeutic procedures (drugs, phototherapy, etc.) without proper prescription in the patients chart (commission error) accounted for 7.4% of the errors, and incidence of omission errors was 8.4%. Incidence of medical errors was significantly higher in newborn infants with lower gestational age. CONCLUSION: Incidence of errors in the care of high-risk newborn infants is elevated. Strategies to improve education of health professionals involved in the care and development of local culture by disseminating clear, accessible algorithms to guide behavior when errors occur must be encouraged.

Original articleInterference of heart and transcutaneous oxygen monitoring in the measurement of bioelectrical impedance analysis in preterm newbornsInterferência da monitoração cardíaca e transcutânea de oxigênio na aferição da bioimpedância elétrica em recém-nascidos pré-termo☆☆☆

OBJECTIVE To verify if the connection of electrodes for heart and transcutaneous oxygen monitoring interfere with the measurement of electrical bioimpedance in preterm newborns. METHODS This was a prospective, blinded, controlled, cross-sectional, crossover study that assessed and compared paired measures of resistance (R) and reactance (Xc) by BIA, obtained with and without monitoring wires attached to the preterm newborn. The measurements were performed in immediate sequence, after randomization to the presence or absence of electrodes. The sample size calculated was 114 measurements or tests with monitoring wires and 114 without monitoring wires, considering for a difference between the averages of 0.1 ohms, with an alpha error of 10% and beta error of 20%, with significance <0.05. RESULTS No differences were observed between the R (677.37±196.07 vs. 677.46±194.86) and Xc (31.15±9.36 vs. 31.01±9.56) values obtained with and without monitoring wires, respectively, with good correlation between them (R: 0.997 and Xc: 0.968). CONCLUSION The presence of heart and/or transcutaneous oxygen monitoring wires connected to the preterm newborn did not affect the values of R or Xc measured by BIA, allowing them to be carried out in this population without risks.