Today, in 21st century healthcare at least 10% of hospitalised patients are subjected to some degree of unintended harm as a result of the treatment they receive. Despite the growing patient safety agenda there is little empirical evidence to demonstrate that patient safety is improving. Patient Safety Leadership Walk Rounds (PSLWR) were introduced to the UK, in March 2005, as a component of the Safer Patients Initiative (SPI), the first dedicated, hospital wide programme to reduce harm in hospital care. PSLWR are designed, to create a dedicated ‘conversation’ about patient safety, between frontline staff, middle level managers and senior executives. This thesis, explored the use of PSLWR, as a proactive mechanism to engage staff in patient safety discussion and detect patient harm within a Scottish healthcare system- NHS Tayside. From May 2005 to June 2006, PSLWR were held on a weekly basis within the hospital departments. A purposive sample, (n=38) of PSLWR discussions were analysed to determine: staff engagement in the process, patient safety issues disclosed; recognition of unsafe systems (latent conditions) and actions agreed for improvement. As a follow-up, 42 semi-structured interviews were undertaken to determine staff perceptions of the PSLWR system. A wide range of clinical and non-clinical staff took part (n=218) including medical staff, staff in training, porters and cleaners, nurses, ward assistants and pharmacists. Participants shared new information, not formally recorded within the hospital incident system. From the participants perspectives, PSLWR, were non threatening; were easy to take part in; demonstrated a team commitment, from the Board to the ward for patient safety and action was taken quickly as a result of the ‘conversations’. Although detecting all patient harm remains a challenge, this study demonstrates PSLWR can be a useful tool in the patient safety arsenal for NHS healthcare organisations.

Neste trabalho foram analisados trinta processos judiciais, que tramitam pelos Fóruns Regionais Cíveis de São Paulo, capital e interior e Instituições Periciais da Capital. Fez-se as extrações individualizadas de cada processo, objetivando definir as principais causas e documentos juntados ao mesmo e conseqüências de cada condição. Iniciou-se pela importância prática do tema para efeito de evolução médico-social. Buscou-se estudar a visão da relação médico-paciente, mesmo durante a demanda, a informação ao paciente e seus familiares dos procedimentos e limitadores do ato médico; o documental técnico jurídico juntado ao processo; o preparo técnico-jurídico do médico e, se, a propositura de ação depende da formação e especialização do profissional. Foram analisados processos judiciais de primeira instância no período de 1996 a 2002 correlacionados à cirurgias do aparelho digestivo. Usou-se como parâmetro de análise exclusivamente os documentos juntados aos autos onde buscou-se a existência clara da quebra da relação médico-paciente, a existência de consentimento informado, a verificação do documental juntado à defesa pelas partes ou solicitação judicial e a qualificação do profissional envolvido nas ações. Finalmente, analisados os resultados, chegamos a conclusão que a melhor forma para profilaxia da ação cível indenizatória por erro médico é: a boa relação médico-paciente; a manutenção de prontuário médico preenchido, legível, com carimbo e assinatura; o consentimento informado, que, deve ser elaborado, porém, por si só não é suficiente; e a condição técnico curricular do profissional não é fator atenuante para propositura da ação. / Thirty legal proceedings, which are in progress before the Regional Civil Courts both the Capital and the countryside of the State of Sao Paulo, Brazil, besides Examination Institutions in the Capital city of Sao Paulo, have been analyzed in this work Individual excerpts of each case were taken with the purpose of defining the main causes and documentation attached to them as well the consequences of each condition. The practical importance of the subject for the medical-social evolution has been addressed in the first place. The physician/patient relationship view was sought to be studied, even during the claim, as well as the information of the medical procedures and limitations to the patient and his or her family; the technical/legal documentation attached to the case; the physician technical/legal preparation and whether the filing of the action depends on the professional education and specialization. Trial court cases from 1996 to 2002 related to digestive system surgery have been analyzed. The analysis subject hereof has been based exclusively on the documents attached to the case record, where attempts have been made to evidence the clear existence of the breach of the physician/patient relationship, the existence of informed consent, the examination of the documentation attached to the defense by the parties or court request, and the qualification of the professional involved in the actions. Finally, after the results have been analyzed, a conclusion was reached that the best way of avoiding a civil action for damages due to medical malpractice includes: a good relationship between doctors and patients; keeping the patient record completed, legible, stamped, and signed; informed consent, which must be prepared but it is not sufficient on its own; and the professional technical experience and background do not constitute a mitigating circumstance for filing the action.

Neste trabalho foram analisados trinta processos judiciais, que tramitam pelos Fóruns Regionais Cíveis de São Paulo, capital e interior e Instituições Periciais da Capital. Fez-se as extrações individualizadas de cada processo, objetivando definir as principais causas e documentos juntados ao mesmo e conseqüências de cada condição. Iniciou-se pela importância prática do tema para efeito de evolução médico-social. Buscou-se estudar a visão da relação médico-paciente, mesmo durante a demanda, a informação ao paciente e seus familiares dos procedimentos e limitadores do ato médico; o documental técnico jurídico juntado ao processo; o preparo técnico-jurídico do médico e, se, a propositura de ação depende da formação e especialização do profissional. Foram analisados processos judiciais de primeira instância no período de 1996 a 2002 correlacionados à cirurgias do aparelho digestivo. Usou-se como parâmetro de análise exclusivamente os documentos juntados aos autos onde buscou-se a existência clara da quebra da relação médico-paciente, a existência de consentimento informado, a verificação do documental juntado à defesa pelas partes ou solicitação judicial e a qualificação do profissional envolvido nas ações. Finalmente, analisados os resultados, chegamos a conclusão que a melhor forma para profilaxia da ação cível indenizatória por erro médico é: a boa relação médico-paciente; a manutenção de prontuário médico preenchido, legível, com carimbo e assinatura; o consentimento informado, que, deve ser elaborado, porém, por si só não é suficiente; e a condição técnico curricular do profissional não é fator atenuante para propositura da ação. / Thirty legal proceedings, which are in progress before the Regional Civil Courts both the Capital and the countryside of the State of Sao Paulo, Brazil, besides Examination Institutions in the Capital city of Sao Paulo, have been analyzed in this work Individual excerpts of each case were taken with the purpose of defining the main causes and documentation attached to them as well the consequences of each condition. The practical importance of the subject for the medical-social evolution has been addressed in the first place. The physician/patient relationship view was sought to be studied, even during the claim, as well as the information of the medical procedures and limitations to the patient and his or her family; the technical/legal documentation attached to the case; the physician technical/legal preparation and whether the filing of the action depends on the professional education and specialization. Trial court cases from 1996 to 2002 related to digestive system surgery have been analyzed. The analysis subject hereof has been based exclusively on the documents attached to the case record, where attempts have been made to evidence the clear existence of the breach of the physician/patient relationship, the existence of informed consent, the examination of the documentation attached to the defense by the parties or court request, and the qualification of the professional involved in the actions. Finally, after the results have been analyzed, a conclusion was reached that the best way of avoiding a civil action for damages due to medical malpractice includes: a good relationship between doctors and patients; keeping the patient record completed, legible, stamped, and signed; informed consent, which must be prepared but it is not sufficient on its own; and the professional technical experience and background do not constitute a mitigating circumstance for filing the action.

Thesis (MCurr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Healthcare organizations have implemented numerous safety initiatives to address errors due to the impact on the patient, families, healthcare provider and the organization as highlighted in the Institute of Medicine report. However, error identification, reporting and management remain a challenge. Nurses have been identified as the healthcare provider with the greatest potential for errors. Supportive work environments are needed to provide optimal care to the nurse who makes an error; which may be minor to severe repercussions. The patient is identified as the first victim and the nurse who makes the error as the second victim. How nurse errors are reported, managed and disclosed is dependent on the response of leaders and peers which may be in a shame and blame or just culture approach. The aim of the study was to assess error management in nursing amongst registered nurses working in a tertiary hospital in Saudi Arabia. The objectives were to identify the occurrence of nursing related errors, determine the current process of reporting nursing errors, describe the management of nursing errors and explore the factors impacting on the management of nursing errors. The research methodology for this study was a descriptive, quantitative approach which is applicable when exploring the unknown. Ethical approval was obtained from the Ethics Board, University of Stellenbosch and the Institutional Review Board, King Faisal Specialist Hospital and Research Centre (General Organization) -Jeddah (KFSH&RC-J). The population was registered nurses working in KFSH&RC-J and assigned to the job descriptions of Staff Nurse 1&2, Clinical Nurse Coordinators and Assistant/Head nurses. Sample was selected using proportional allocation for nationality and simple random selection for nursing specialty; 215 RNs from these three groups. Data was collected using a questionnaire developed by the researcher and analysis completed using SPSS and regression analysis to identify factors which influences the reporting and management of errors. Data was presented in the form of frequency tables and graphs using the EXCEL program to analyze the data. The main findings of the study; there was significant difference in nurse leaders and professional nurses ability to identify nursing errors; questioning of the practice of peers, views of a non-punitive environment and the ability to differentiate between error and negligence. The nurse executive was positively associated with the average positive responses received. RNs of Middle Eastern nationality and the Adult nursing division were found to be slightly more negative in their perceptions about error reporting and management than other respondents. Improvements are needed in the processes of error reporting and management which include education; leadership development, underreporting of errors, feedback and communication, nurse manager support and disclosure of errors. Recommendations are the implementation of the Just Culture principles within the organization and leadership development to address error reporting and management. The need to develop a national database for error reporting in Saudi Arabia is recommended. Nursing errors occurred in one tertiary hospital in Saudi Arabia and an on-line system is available to report errors. However, nurses do not report errors as they fear being blamed and shamed. The process of error management within the organization has not been clearly defined. / AFRIKAANSE OPSOMMING: Gesondheidsorganisasies het talle veiligheids inisiatiewe geïmplementeer om foute aan te spreek weens die invloed wat dit het op die pasiënt, families, die gesondheidsverskaffer en die organisasie soos uitgelig in die Mediese Verslag van die Instituut. Nietemin, die identifisering van foute, verslaggewing en bestuur bly ’n uitdaging. Verpleegsters is geïdentifiseer as die gesondheidsverskaffers wat oor die grootste potensiaal beskik om foute te begaan. Ondersteunende werkomgewings word benodig om optimale sorg aan die verpleegster te verskaf wat ’n fout van ’n mindere aard tot die met ernstige gevolge begaan. Die pasiënt word geïdentifiseer as die eerste slagoffer en die verpleegster wat die fout begaan as die tweede slagoffer. Die manier hoedat verpleegfoute gerapporteer, bestuur en openbaar gemaak word, is afhanklik van die reaksies van leiers en portuurgroepe wat ’n skaamte- en blameerbenadering of “just culture”-benadering kan wees. Die doel van die studie was om die hantering van verpleegfoute tussen geregistreerde vepleegkundiges wat in n tersiêre hospital in Saudi werk te ondersoek. Die doelwitte is om die voorkoms van verpleegverwante foute te identifiseer, die huidige proses van verslaggewing van verpleegfoute te bepaal, die bestuur van verpleegfoute te beskryf en die faktore te ondersoek wat ’n impak het op die bestuur van verpleegfoute. Die navorsingsmetodologie vir hierdie studie is ’n beskrywende, kwantitatiewe benadering wat van toepassing is wanneer die onbekende ondersoek word. Etiese goedkeuring is verkry van die Etiese Raad aan die Universiteit Stellenbosch en die Institusionele Beoordelingsraad, King Faisal Specialist Hospitaal en Navorsingssentrum (Algemene Organisasie) – Jeddah (KFSH & RC-J). Die teikengroep is geregistreerde verpleegsters wat werk in KFSH & RC-J aan wie die posbeskrywing van stafverpleegster 1 & 2 toegeken is, Kliniese Verpleegkoördineerders en Assistent/Hoofverpleegsters. Die steekproef is geselekteer deur gebruik te maak van proporsionele toekenning vir nasionaliteit en ’n eenvoudige ewekansige steekproef vir verpleegspesialiteit; 215 geregistreerde verpleegsters van hierdie drie groepe. Data is gekollekteer deur gebruik te maak van ’n vraelys wat deur die navorser ontwikkel is en die analise is voltooi deur gebruik te maak van SPSS en regressie-analise om faktore te identifiseer wat verslaggewing en bestuur van foute beïnvloed. Data is aangebied in die vorm van frekwensie-tabelle en grafieke deur gebruik te maak van die EXCEL-program om die data te analiseer. Die vernaamste bevindinge van die studie is dat daar beduidende verskille tussen verpleegleiers en professionele verpleegsters se vermoë is om verpleegfoute te identifiseer; bevraagtekening van die praktyke van portuurgroepe; beskouinge van nie-strafgerigte omgewing en die vermoë om te onderskei tussen foute en nalatigheid. Die verpleegeksekuteur is positief geassosieer met die gemiddelde positiewe response wat ontvang is. Geregistreerde verpleegsters van Midde-Oostelike nasionaliteit en die Volwasse Verpleegafdeling is gevind om effens meer negatief te wees in hulle persepsies van fouteverslaggewing en bestuur, as ander respondente. Verbeterings is nodig in die prosesse van verslaggewing van foute en bestuur daarvan wat opvoeding daarvan insluit; leierskapontwikkeling, onderverslaggewing van foute, terugvoer en kommunikasie, ondersteuning van verpleegbestuur en bekendmaking van foute. Aanbevelings is die implementering van die “Just”-kultuur beginsels binne die organisasie en leierskap ontwikkeling om die verslag van foute en bestuur aan te spreek. Die behoefte om ’n nasionale databasis te ontwikkel vir die verslag van foute in Saoedi-Arabië word aanbeveel. Verpleegfoute het in een tersiêre hospitaal in Saoedi-Arabië plaasgevind en ’n aanlyn sisteem is beskikbaar gestel om foute te rapporteer. Nietemin, verpleegsters rapporteer nie foute nie, want hulle vrees om geblameer te word en beskaamd te staan. Hierdie proses van foutebestuur binne die organisasie is nog nie duidelik gedefinieer nie.

Introdução: idosos hospitalizados apresentam maior risco de sofrer eventos adversos na internação que adultos jovens, com consequências mórbidas significativas. O objetivo deste estudo é estimar prospectivamente a freqüência de eventos adversos médicos, os fatores de risco para sua ocorrência e sua relação com óbito intrahospitalar em idosos admitidos aos leitos destinados a cuidados de descompensações clínicas agudas de uma enfermaria de geriatria. Métodos: estudo de coorte prospectivo incluindo as admissões de pacientes com 60 anos ou mais aos leitos destinados a cuidados de descompensações clínicas agudas da Enfermaria de Geriatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com duração maior de 24 horas, entre abril de 2007 e julho de 2008. Na admissão foram obtidos dados sobre sexo, idade, número de drogas utilizadas, presença de síndromes geriátricas (imobilidade, instabilidade postural, incontinência esfincteriana, demência, depressão e delirium), comorbidades, status funcional (índice de Katz) e gravidade de doença (SAPS II). Durante o período de internação avaliou-se a ocorrência de delirium, infecção, a prescrição de medicamentos inapropriados ao idoso (critérios de Beers) e óbito intrahospitalar. Um observador não envolvido nos cuidados dos pacientes relatou a ocorrência de eventos adversos médicos. Resultados: foram incluídas 171 admissões de pacientes, com idade média de 78,12 anos ± 9,27, sendo 101 do sexo feminino. Ocorreram 187 eventos adversos médicos em 94 admissões (55%), com 2,01 eventos por admissão. Não foi possível identificar fatores preditores da ocorrência de eventos adversos médicos. As admissões com ocorrência de eventos adversos apresentaram maior tempo de internação na enfermaria de geriatria (21,41 dias ± 15,08 X 10,91 dias ± 7,21, p<0,001) e maior mortalidade intra-hospitalar que as admissões onde não houve eventos. Como fatores preditores de mortalidade intra-hospitalar após análise multivariada identificou-se o SAPS II (Razão de chances (OR)=1,13, intervalo de confiança (IC) 95% 1,07-1,20, p<0,001), índice de Katz na admissão (OR=1,47, IC 95% 1,18-1,83, p=0,001) e ocorrência de eventos adverso médico (OR=3,59, IC 95% 1,55-8,30, p=0,003). Conclusões: Eventos adversos médicos devem ser considerados em todo idoso hospitalizado uma vez que são bastante frequentes nessa população. Não há um perfil de risco para indivíduos suscetíveis. Estes eventos apresentam impacto na mortalidade e no tempo de internação. / Introduction: hospitalized seniors are at higher risk of adverse events than young adults and it is a morbid condition. The aim of this study is to prospectively estimate the frequency of medical adverse events in elderly patients admitted to an acute care geriatric ward, the predictive factors to its occurrence, and their implication in death during hospitalization. Methods: prospective cohort study including the admissions of elderly patients that lasted more than 24 hours to the acute care session of the geriatric ward in Hospital das Clínicas of Faculdade de Medicina, Universidade de São Paulo, between 2007 and 2008. At admission the variables assessed were age, gender, number of drugs, geriatric syndromes (immobility, postural instability, dementia, depression, delirium and incontinency), comorbidities, functional status (Katz Score), and severity of illness (SAPS II). During hospitalization, the occurrence of delirium, infection, the prescription of potentially inappropriate medications according to Beers criteria and death were assessed. An observer not involved in the patients care reported the medical adverse events. Results: 171 admissions were enrolled in the study, mean age 78.12 ± 9.27 years, 101 females. 187 medical adverse events occurred in 94 admissions (55%), with 2.01 events per admission. Predictors to medical adverse events were not found. Time of hospitalization (21.41 days ± 15.08 X 10.91 days ± 7.21, p<0.001) and mortality (39 (41.5%) X 17 (22.1%), p=0.007) were respectively longer and higher in the admissions with medical adverse events. Death was independently predicted by SAPS II (Odds-ratio (OR)=1.13, Confidence interval (CI) 95% 1.07-1.20, p<0.001), Katz score (OR=1.47, CI 95% 1.18-1.83, p=0.001), and medical adverse events (OR=3.59, CI 95% 1.55-8.30, p=0.003). Conclusion: Medical adverse events shall be sought in every hospitalized older adult since there is not a risk profile of susceptible patients, and its burden is high, leading to death and longer hospital stays.

Sömnbrist är ett ämne som givits allt mer uppmärksamhet i dagens samhälle. Sömnen har betydelse för människan i den bemärkelse att kroppen får återhämtning och hjärnan kan lagra och bearbeta minnen. Sjuksköterskor har i dagens samhälle en stor roll i det patientnära arbetet. Men vad händer med en sjuksköterska som har sömnbrist och hur påverkar detta hens arbete och hälsa? Syftet med detta arbete är att beskriva hur sjuksköterskor erfar sömnbrist, trötthet och fatigue samt hur det påverkar sjuksköterskans arbete och hälsa. En litteraturöversikt användes till arbetet för att få en överblick om det nuvarande kunskapsläget. Tio artiklar inkluderades i arbetet och analyserades. Studier visar på att sömnbrist, trötthet och fatigue är vanligt förekommande hos sjuksköterskor och studierna visade även på konsekvenser som uppstått till följd av sjuksköterskors trötthet. Dessa konsekvenser kan innebära att sjuksköterskor begår misstag i det patientnära arbetet, men tröttheten kan också gå ut över det privata livet. Detta innebär att sjuksköterskan kan utsätta sig för onödiga risker utanför arbetsplatsen i form av att köra bil medan hen är trött. Resultaten visar att det behövs mer forskning kring vilka orsaker som gör att sjuksköterskan lider av sömnbrist och därav upplever trötthet. Likaså studier som visar hur sömnbrist påverkar den vårdande vården vore värdefullt. En slutsats är att man bör lyfta frågan om sömnbrist och trötthet hos personalen för att på så sätt kunna se om rätt förutsättningar finns för en rimlig återhämtning.

Orientador: Silvana Andrea Molina Lima / Resumo: A Organização Mundial de Saúde (OMS) estabelece que segurança do paciente consiste na redução do risco de dano desnecessário associado ao cuidado de saúde ao mínimo aceitável. A ocorrência de incidentes no atendimento de pacientes hospitalizados pode acarretar incapacidades temporárias ou permanentes, complicações na sua recuperação e aumento no tempo médio de internação. É importante que as instituições conheçam esses incidentes, analise os fatores contribuintes para criar planos de ações de melhoria. Por essa razão, é essencial que os incidentes sejam comunicados voluntariamente pelos profissionais e os sistemas informatizados mais utilizados como ferramenta para essas notificações. O presente trabalho teve como objetivo analisar os incidentes relacionados à assistência em saúde, registrados no sistema de notificação de incidentes de um hospital especializado em oncologia do interior do estado de São Paulo. Trata-se de um estudo descritivo, retrospectivo, de abordagem quantitativa a partir de fonte secundária de dados. A análise dos dados revelou que a maioria das notificações estava adequada, evidenciando o comprometimento dos profissionais de saúde e da gestão com a segurança do paciente. Verificou-se que a maioria das ocorrências foi classificada como evento adverso com dano leve. Os principais incidentes registrados foram relacionados aos medicamentos, queda e extravasamento de quimioterápicos. O estudo leva à conclusão que o monitoramento das ocorrências de incidentes ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The World Health Organization (WHO) establishes that patient safety corresponds to the reduction of risk of unnecessary harm associated with health care to an acceptable minimum. The occurrence of incidents in inpatient care can lead to temporary or permanent disabilities, complications in their recovery and increase in the average time of hospitalization. It is important for institutions to know about these incidents, analyze the contributing factors to create plans for improvement actions. Therefore, it is essential that incidents are voluntarily reported by professionals and computer systems most used as a tool for such notifications. The present study aimed to analyze the incidents related to health care, recorded in the incident reporting system of a hospital specialized in oncology located in the interior of the state of São Paulo. It is a descriptive, retrospective study of quantitative approach from a secondary source of data. The analysis of data revealed that most of the reports were adequate, evidencing the commitment of health professionals and management to patient safety. It was found that most of the occurrences were classified as adverse events with mild damage. The main incidents reported were related to medication, fall and extravasation of chemotherapy. The study concludes that monitoring incidents occurrence in institutions is extremely important for the adoption of preventive and corrective measures, ensuring greater patient safety. As product, a folder o... (Complete abstract click electronic access below) / Mestre

Introdução: idosos hospitalizados apresentam maior risco de sofrer eventos adversos na internação que adultos jovens, com consequências mórbidas significativas. O objetivo deste estudo é estimar prospectivamente a freqüência de eventos adversos médicos, os fatores de risco para sua ocorrência e sua relação com óbito intrahospitalar em idosos admitidos aos leitos destinados a cuidados de descompensações clínicas agudas de uma enfermaria de geriatria. Métodos: estudo de coorte prospectivo incluindo as admissões de pacientes com 60 anos ou mais aos leitos destinados a cuidados de descompensações clínicas agudas da Enfermaria de Geriatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, com duração maior de 24 horas, entre abril de 2007 e julho de 2008. Na admissão foram obtidos dados sobre sexo, idade, número de drogas utilizadas, presença de síndromes geriátricas (imobilidade, instabilidade postural, incontinência esfincteriana, demência, depressão e delirium), comorbidades, status funcional (índice de Katz) e gravidade de doença (SAPS II). Durante o período de internação avaliou-se a ocorrência de delirium, infecção, a prescrição de medicamentos inapropriados ao idoso (critérios de Beers) e óbito intrahospitalar. Um observador não envolvido nos cuidados dos pacientes relatou a ocorrência de eventos adversos médicos. Resultados: foram incluídas 171 admissões de pacientes, com idade média de 78,12 anos ± 9,27, sendo 101 do sexo feminino. Ocorreram 187 eventos adversos médicos em 94 admissões (55%), com 2,01 eventos por admissão. Não foi possível identificar fatores preditores da ocorrência de eventos adversos médicos. As admissões com ocorrência de eventos adversos apresentaram maior tempo de internação na enfermaria de geriatria (21,41 dias ± 15,08 X 10,91 dias ± 7,21, p<0,001) e maior mortalidade intra-hospitalar que as admissões onde não houve eventos. Como fatores preditores de mortalidade intra-hospitalar após análise multivariada identificou-se o SAPS II (Razão de chances (OR)=1,13, intervalo de confiança (IC) 95% 1,07-1,20, p<0,001), índice de Katz na admissão (OR=1,47, IC 95% 1,18-1,83, p=0,001) e ocorrência de eventos adverso médico (OR=3,59, IC 95% 1,55-8,30, p=0,003). Conclusões: Eventos adversos médicos devem ser considerados em todo idoso hospitalizado uma vez que são bastante frequentes nessa população. Não há um perfil de risco para indivíduos suscetíveis. Estes eventos apresentam impacto na mortalidade e no tempo de internação. / Introduction: hospitalized seniors are at higher risk of adverse events than young adults and it is a morbid condition. The aim of this study is to prospectively estimate the frequency of medical adverse events in elderly patients admitted to an acute care geriatric ward, the predictive factors to its occurrence, and their implication in death during hospitalization. Methods: prospective cohort study including the admissions of elderly patients that lasted more than 24 hours to the acute care session of the geriatric ward in Hospital das Clínicas of Faculdade de Medicina, Universidade de São Paulo, between 2007 and 2008. At admission the variables assessed were age, gender, number of drugs, geriatric syndromes (immobility, postural instability, dementia, depression, delirium and incontinency), comorbidities, functional status (Katz Score), and severity of illness (SAPS II). During hospitalization, the occurrence of delirium, infection, the prescription of potentially inappropriate medications according to Beers criteria and death were assessed. An observer not involved in the patients care reported the medical adverse events. Results: 171 admissions were enrolled in the study, mean age 78.12 ± 9.27 years, 101 females. 187 medical adverse events occurred in 94 admissions (55%), with 2.01 events per admission. Predictors to medical adverse events were not found. Time of hospitalization (21.41 days ± 15.08 X 10.91 days ± 7.21, p<0.001) and mortality (39 (41.5%) X 17 (22.1%), p=0.007) were respectively longer and higher in the admissions with medical adverse events. Death was independently predicted by SAPS II (Odds-ratio (OR)=1.13, Confidence interval (CI) 95% 1.07-1.20, p<0.001), Katz score (OR=1.47, CI 95% 1.18-1.83, p=0.001), and medical adverse events (OR=3.59, CI 95% 1.55-8.30, p=0.003). Conclusion: Medical adverse events shall be sought in every hospitalized older adult since there is not a risk profile of susceptible patients, and its burden is high, leading to death and longer hospital stays.

Orientador: Patrícia de Carvalho Mastroianni / Resumo: Estima-se que a notificação espontânea de incidentes capture apenas 10% dos eventos ocorridos em instituições hospitalares. Entretanto, a educação em saúde pode contribuir para o estímulo do aumento do índice de notificações assim como para a segurança do paciente. Diante disso, o objetivo do estudo foi avaliar a efetividade de uma Intervenção Educativa (IE) para promoção da notificação de incidentes em saúde para profissionais de um hospital de ensino no interior do estado de São Paulo. O estudo foi do tipo experimental, aberto, não randomizado e houve adaptação da IE através de um pré-treinamento com alunos de graduação da Faculdade de Ciências Farmacêuticas da Unesp. Os profissionais incluídos no estudo foram aqueles cuja atuação fosse da área assistencial. Foram excluídos, profissionais afastados por um período maior do que três meses, estagiários e residentes. A participação dos profissionais na IE foi feita através da alocação por conveniência, com formação de três turmas, de acordo com turno de trabalho dos participantes. A IE foi realizada durante três meses, por meio de aulas expositivas, divididas em quatro módulos com duração de 60 minutos cada, realizados em dias alternados por duas semanas, além da aplicação de questionário antes e depois. As variáveis analisadas estavam relacionadas ao conhecimento, habilidade e atitude em notificação. As respostas dos questionários, assim como a quantidade e qualidade dos itens preenchidos na ficha de notificação foram avaliada... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

The high incidence of medical and surgical errors in U.S. hospitals and clinics affects patients' safety. Not enough is known about the relationship between physician characteristics and medical error rates. The purpose of this quantitative correlational study was to examine the relationship between selected physician characteristics and surgical errors in U.S. hospitals. The ecological model was used to understand personal and systemic factors that might be related to the incidence of surgical errors. Archived data from the National Practitioner Data Bank database of physician surgical errors were analyzed using bivariate and multivariate logistic regression analyses. Independent variables included physicians' home state, state of license, field of license, age group, and graduation year group. The dependent variable was surgical medical errors. Physicians' field of license and state of license were significantly associated with surgical error. Findings contribute to the knowledge base regarding the relationship between physician characteristics and surgical medical errors, and findings may be used to improve patient safety and medical care.