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Title: Accuracy and completeness of records of adverse events through interface terminology
Author: González Samartino, Maribel
Delgado-Hito, Pilar
Adamuz, Jordi
Viso Cano, Maria Fe
Castellà Creus, Mònica
Juvé Udina, Eulàlia
Keywords: Pneumònia
Infermeria quirúrgica
Úlcera per pressió
Surgical nursing
Issue Date: 1-Jan-2018
Publisher: Universidade de São Paulo
Abstract: Objective: To determine what adverse events, including pressure ulcers, infection of the surgical site and aspiration pneumonia, nurses record in clinical histories, in terms of diagnostic accuracy and completeness, through ATIC. Method: Observational, descriptive, cross-sectional, multicenter study of 64 medical-surgical and semi-critical units of two university hospitals in Catalonia, Spain, during 2015. e diagnostic accuracy was assessed by means of the correspondence between the event declared in the Minimum Basic Data Set and the problem documented by the nurse. e record was considered complete when it contained the risk of the event, prescriptions of care and a record of the evolution. Results: e sample evaluated included 459 records. e accuracy results of pressure ulcers are highly correlated between the nursing diagnosis recorded and that declared in the Minimum Basic Data Set. e accuracy in surgical site infection is moderate, and aspiration resulting in pneumonia is very low. e completeness of results is remarkable, except for the risk of bronchoaspiration. Conclusion: e adverse event recorded by nurses with greatest accuracy is pressure ulcers.
Note: Reproducció del document publicat a:
It is part of: Revista da Escola de Enfermagem da USP, 2018, vol. 52, num. e03306
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ISSN: 0080-6234
Appears in Collections:Articles publicats en revistes (Infermeria Fonamental i Medicoquirúrgica)
Articles publicats en revistes (Institut d'lnvestigació Biomèdica de Bellvitge (IDIBELL))

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