Factores de riesgo asociados a eventos adversos por medicación notificados por enfermería en un Hospital Pediátrico de México

Abstract

Introduction

During pediatric medication administration, patient safety-related incidents such as sentinel event, adverse event or quasi-failure still occur.

Objective

To identify risk factors associated with adverse events during the medication of pediatric patients reported by nurses.

Methods

Cross-sectional study, non-probabilistic sampling. From January to October 2021, 411 reports from the Vencer II System were reviewed, of which only 140 reported notifications of incidents during the medication of pediatric patients. Using root cause analysis 38 factors associated with adverse events were investigated. Descriptive and inferential statistics were used.

Results

Of the 411 reports reviewed, 140 (34.0%) correspond to incidents; 116 (83.0%) to adverse events and 24 (17.0%) to quasi-failure, no sentinel events were reported. In the human factor, 6 of the 7 proximal factors had a frequency ≥ 40%. Work overload was significantly associated with the occurrence of adverse events; OR = 3.24 (95% CI, 1.31-7.99) (P=.008). Contrary to what has been reported, LASA (Look-Alike, Sound-Alike) medications and double-check omission were identified as protective against the occurrence of incidents; OR = 0.323 (95% CI, 0.13-0.84) (p = 0.017); OR = 0.39 (95% CI, 0.15-0.99) (P=.047).

Conclusions

Work overload was identified as a risk factor associated with the occurrence of adverse events, so it is necessary to evaluate this factor from objective medication and from the nurses’ perception of it. Having a documented incident notification and response system in place will allow healthcare institutions to demonstrate diligence and transparency. Finally, the usefulness of root cause analysis and the Ishikawa diagram to identify factors that can cause incidents is again supported, so their integration into the VENCER II instrument would be useful.