Os eventos adversos a medicamentos (EAMs) são causa importante de comprometimento da qualidade da atenção ao paciente hospitalizado e, por isso, devem ser identificados e caracterizados. Para tanto surgiram listas de rastreadores, entre elas a proposta pelo Institute for Healthcare Improvement. Aqui é apresentado o processo da aplicação dos rastreadores e o seu desempenho em um hospital de ensino. As informações sobre os rastreadores e os EAM foram coletadas por meio de revisão retrospectiva dos prontuários de pacientes com alta hospitalar de janeiro a junho de 2008. Foram identificados 497 rastreadores em 177 prontuários, onde cada prontuário apresentou, em média, 2,33 (DP = 2,7) rastreadores. Os encontrados com mais frequência foram: "antiemético" (72,1/100 prontuários), "interrupção abrupta da medicação" (70,0/100 prontuários) e "sedação excessiva, sonolência, torpor, letargia, queda e hipotensão" (34,6/100 prontuários). Os mais eficientes na captura de EAM (rendimento), isto é, aqueles que uma vez identificados sinalizaram possíveis eventos foram "antagonista de benzodiazepínico", "antidiarréicos" e "rash cutâneo". Os EAM mais encontrados foram relacionados aos rastreadores "interrupção abrupta da medicação" (8,3/100 prontuários), "antiemético" (4,6/100 prontuários) e "rash cutâneo" (2,1/100 prontuários). Essas considerações apontam para a utilidade do emprego da lista de rastreadores e podem contribuir para decidir sobre ajustes na sua aplicação.

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Objectives The present database contains information on patient falls in the hospital setting. Data were collected in January 2018 with of describing in-hospital falls reported from 1st January 2012 to 31 December 2017 in a large hospital in the South of Brazil. Learning about the characteristics of these events and establishing a profile may contribute to the design of adequate prevention and improvement strategies that are effective to reduce the risk of falls. Data description This data set encompasses 1.071 in-patients falls characterized by the follow variables: year, date, patient birth, weekday, shift, department/location of the incident, location, severity, presence of companion, age, sex, risk level, medication associated with fall risk, implemented fall prevention protocol, type of injury, reason, restraint prescription, physical therapy prescription.

BACKGROUND: Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. OBJECTIVE: To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. METHOD: We performed a descriptive retrospective study of near-miss incidents recorded in the hospital’s electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson’s chi-square test, Fisher’s exact test (Monte Carlo simulation) and linear regression were used. RESULTS: A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. CONCLUSION: The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

ABSTRACT. The study aimed to assess the current situation of medication administration via nasogastric tube (VNGT) and identify weaknesses in the process. As a tool, the application of questionnaires to the professionals of the nursing service was used. The questionnaire contained questions and each of them, during the correction, was assigned a specific score. The participant could according to the evaluation system get a grade of 0 to 100 points. Among the participants, 66.7% stated that they had already received some guidance on medication administration via the tube, and after correction and assignment of the notes, the averages obtained were: 47.3 points by the nurses; 38.7 points by nursing technicians; 34.5 points for resident nurses; and 37.0 points by the nursing assistants. The findings of the study indicate that there is a difference between the usual practice and the recommended practice in the literature and the professionals knowledge about administration of medication VNGT is still limited. The insertion of the pharmacist in the multidisciplinary team and disseminating knowledge on incompatibilities, interactions and reactions are of great importance for the improvement of this scenario.Keywords: pharmaceutical preparations, enteral nutrition, nutritional therapy, nursing care.Conceitos aplicados na prática diária na administração de medicamentos via sonda nasoenteral pela equipe de enfermagem RESUMO. O estudo teve por objetivos avaliar o panorama atual da administração de medicamentos via sonda nasoenteral (VSNE) e identificar as fragilidades nesse processo. Como ferramenta utilizou-se a aplicação de questionários aos profissionais do serviço de enfermagem. O questionário continha questões e a cada uma delas, durante a correção, atribuiu-se uma pontuação específica. O participante poderia de acordo com o sistema de avaliação obter uma nota de 0 a 100 pontos. Dentre os participantes, 66,7% afirmaram já ter recebido alguma orientação sobre a administração de medicamentos, via sonda, e após correção e atribuição das notas, as médias obtidas foram: 47,3 pontos pelos enfermeiros; 38,7 pontos pelos técnicos em enfermagem; 34,5 pontos pelos enfermeiros residentes; e 37,0 pontos pelos auxiliares de enfermagem. Os achados do estudo indicam que existe diferença entre a prática usual com o recomendado na literatura e o conhecimento dos profissionais sobre administração de medicamentos VSNE ainda é limitado. A inserção do farmacêutico na equipe multidisciplinar e disseminação do conhecimento referente às incompatibilidades, interações e reações presentes são de grande importância para a melhoria deste cenário.Palavras-chave: preparações farmacêuticas, nutrição enteral, terapia nutricional, cuidados de enfermagem.