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Si us plau utilitzeu sempre aquest identificador per citar o enllaçar aquest document: https://hdl.handle.net/2445/124104
Accuracy and completeness of records of adverse events through interface terminology
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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.
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GONZÁLEZ SAMARTINO, Maribel, DELGADO-HITO, Pilar, ADAMUZ TOMÁS, Jordi, VISO CANO, Maria fe, CASTELLÀ CREUS, Mònica, JUVÉ UDINA, Eulàlia. Accuracy and completeness of records of adverse events through interface terminology. _Revista da Escola de Enfermagem da USP_. 2018. Vol. 52, núm. e03306. [consulta: 21 de gener de 2026]. ISSN: 0080-6234. [Disponible a: https://hdl.handle.net/2445/124104]