Palavras-chave
Dano ao Paciente
Análise de Causa Raiz
Segurança do Paciente
Como Citar
Resumo
Objetivo: Descrever a análise de eventos adversos graves relacionados a quedas de pacientes hospitalizados e as ações planejadas à luz do Protocolo de Londres. Método: Estudo observacional, transversal e descritivo, realizado com amostra não probabilística de pacientes hospitalizados que sofreram quedas graves no período de janeiro de 2020 a dezembro de 2024. A coleta de dados foi conduzida por meio de notificações de quedas, prontuários eletrônicos dos pacientes e relatórios de análise dos eventos. Resultados: Foram identificadas 14 quedas graves no período. Dessas, nove ocorreram no período noturno (64,3%), nove em pacientes do sexo masculino (64,3%), nove na faixa etária de 60 a 74 anos (64,3%), sete em pacientes com ensino fundamental incompleto (50,0%) e oito em serviços de especialidades clínicas (57,1%). Quanto aos danos provocados, oito casos resultaram em fraturas (57,1%), cinco em traumatismo cranioencefálico (35,7%) e um em lesão com laceração (7,1%). Dos 14 pacientes que sofreram quedas graves, seis (42,9%) evoluíram para óbito decorrente do evento. Conclusão: A partir da análise dos eventos de queda, foram propostas ações sistêmicas estruturais, educativas e gerenciais, visando ao aprendizado organizacional.
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