Palabras clave
Daño al Paciente
Análisis de Causa Raíz
Seguridad del Paciente
Cómo citar
Resumen
Objetivo: Describir el análisis de eventos adversos graves relacionados con caídas de pacientes hospitalizados y las acciones planificadas a la luz del Protocolo de Londres. Método: Estudio observacional, transversal y descriptivo, realizado con una muestra no probabilística de pacientes hospitalizados que sufrieron caídas graves en el período de enero de 2020 a diciembre de 2024. La recolección de datos se llevó a cabo mediante notificaciones de caídas, historias clínicas electrónicas de los pacientes y informes de análisis de eventos. Resultados: Se identificaron 14 caídas graves en el período. De estas, nueve ocurrieron durante el turno nocturno (64,3%), nueve en pacientes del sexo masculino (64,3%), nueve en el grupo etario de 60 a 74 años (64,3%), siete en pacientes con educación primaria incompleta (50,0%) y ocho en servicios de especialidades médicas (57,1%). En cuanto a los daños provocados, ocho casos resultaron en fracturas (57,1%), cinco en traumatismo craneoencefálico (35,7%) y uno en lesión con laceración (7,1%). De los 14 pacientes que sufrieron caídas graves, seis (42,9%) evolucionaron hacia el óbito a consecuencia del evento. Conclusión: A partir del análisis de los eventos de caída, se propusieron acciones sistémicas estructurales, educativas y de gestión, orientadas al aprendizaje organizacional.
Referencias
Heng H, Kiegaldie D, Shaw L, Jazayeri D, Hill AM, Morris ME. Implementing patient falls education in hospitals: a mixed-methods trial. Healthcare (Basel). 2022;10(7):1298. https://doi.org/10.3390/healthcare10071298. PMID: 35885823.
Morris ME, Webster K, Jones C, Hill AM, Haines T, McPhail S, et al. Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age Ageing. 2022;51(5):1-12. https://doi.org/10.1093/ageing/afac077. PMID: 35524748.
Liang XZ, Chai JL, Li GZ, Li W, Zhang BC, Zhou ZQ, et al. A fall risk prediction model based on the CHARLS database for older individuals in China. BMC Geriatr. 2025 Mar 13;25(1):170. https://doi.org/10.1186/s12877-025-05814-y. PMID: 40082807.
World Health Organization. Step Safety: strategies for preventing and managing falls across the life-course [Internet]. Geneva: WHO; 2021 [cited 2025 May 28]. Available from: https://iris.who.int/bitstream/handle/10665/340962/9789240021914-eng.pdf?sequence=1
Lima J da S, Quadros DV, Silva SLC da, Tavares JP, Dal Pai D. Custos das autorizações de internação hospitalar por quedas de idosos no Sistema Único de Saúde, Brasil, 2000-2020: um estudo descritivo. Epidemiol Serv Saúde. 2022;31(1):1-12. https://doi.org/10.1590/S1679-49742022000100012. PMID: 35588512.
Dykes PC, Curtin-Bowen M, Lipsitz S, Franz C, Adelman J, Adkison L, et al. Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. JAMA Health Forum. 2023;4(1):e225125 https://doi.org/10.1001/jamahealthforum.2022.5125. PMID: 36662505.
Quadros DV, Magalhães AMM, Wachs P, Severo IM, Tavares JP, Dal Pai D. Modeling of adult patient falls and the repercussions to Nursing as a second victim. Rev Lat Am Enfermagem. 2022;30:e3617. https://doi.org/10.1590/1518-8345.5830.3617. PMID: 35920541.
Agência Nacional de Vigilância Sanitária (BR). Relatório de incidentes e eventos adversos não infecciosos relacionados à assistência à saúde: Brasil, 2014–2021 [Internet]. Brasília: ANVISA; 2022 [cited 2025 May 15]. Available from: https://www.gov.br/anvisa/pt-br/assuntos/servicosdesaude/notificacoes/notificacao-de-incidentes-eventos-adversos-nao-infecciosos-relacionados-a-assistencia-a-saude/relatorios-de-incidentes-eventos-adversos-relacionados-a-assistencia-a-saude/BR_2014__2021_1.pdf
Ximenes MAM, Brandão MGSA, Macêdo TS, Costa MMF, Galindo NM, Caetano JÁ, et al. Efetividade de tecnologia educacional para prevenção de quedas em ambiente hospitalar. Acta Paul Enferm. 2022;35:eAPE003765. https://doi.org/10.37689/acta-ape/2022AO01372
Quadros DV, Magalhães AMM, Lopes EFS, Lima JS, Boufleuer E, Dal Pai D. Prevenção de quedas na hospitalização: oportunidades educativas na perspectiva dos trabalhadores de enfermagem. Rev Enferm UFSM. 2024;14:e3. https://doi.org/10.5902/2179769284145
Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320(7237):777-81. https://doi.org/10.1136/bmj.320.7237.777. PMID: 10720366.
Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London protocol. Clin Risk. 2004;10(6):211-20. https://doi.org/10.1258/1356262042368255
Reason J. Human error. Cambridge: Cambridge University Press; 1990.
Vincent C, Adams S, Bellandi T, Michel P, Staines A. Systems analysis of clinical incidents: The London Protocol. [place unknown: publisher unknown]; 2024 [cited 2025 May 28]. 48 p. Available from: https://fhv.ch/wp-content/uploads/2024/09/the-london-protocol_september-2024.pdf
Giaquinto BCD, Oliveira CMC, Costa CCA, Barros KGD, Manzo BF, Corrêa AR. Accidents from falls among hospitalized patients in Emergency Units: a multicenter study. Rev Bras Enferm. 2026;79:e20240320. https://doi.org/10.1590/0034-7167-2024-0320. PMID: 41919812.
Ghosh M, O’Connell B, Afrifa-Yamoah E, Kitchen S, Coventry L. A retrospective cohort study of factors associated with severity of falls in hospital patients. Sci Rep. 2022;12:12266. https://doi.org/10.1038/s41598-022-16403-z. PMID: 35851400.
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344-9. https://doi.org/10.1136/bmj.39335.541782.AD. PMID: 17947786.
Joint Commission International [Internet]. Oakbrook Terrace (IL): Joint Commission International; c2025 [cited 2025 May 15]. Available from: https://www.jointcommissioninternational.org/resources/news/2024/07/jci-publishes-8th-edition-of-international-accreditation-standards/
Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 2009;21(1):18-26. https://doi.org/10.1093/intqhc/mzn057. PMID: 19147597.
García-Hedrera FJ, Noguera-Quijada C, Sanz-Márquez s, Pérez-Fernández E, Acevedo-García M, Dominguéz-Rincón R, et al. Incidence and characteristics of falls in hospitalized patients: a cohort study. Enferm Clín (Engl Ed). 2021;31(6):381–9. https://doi.org/10.1016/j.enfcle.2021.04.003. PMID: 34674988.
Hamilton MP, Bellolio F, Jeffery MM, Bower SM, Palmer AK, Tung EE, et al. Risk of falls is associated with 30-day mortality among older adults in the emergency department. Am J Emerg Med. 2024;79:122-6. https://doi:10.1016/j.ajem.2024.02.020. PMID: 38422753.
Silvestre FMM, Entradas CACN. Fatores relacionados com a incidência de quedas em contexto hospitalar: uma revisão de literatura. REASE. 2025;11(2):1-9. https://doi.org/10.51891/rease.v11i2.18112
Dornelles C, Aguiar JRV, Bonati MM, Prado ARA. Caídas en el entorno hospitalario entre 2009 y 2019: una revisión integradora. Rev Urug Enferm. 2022;17(1):e2022v17n1a11. https://doi.org/10.33517/rue2022v17n1a11
Maruszewska A, Ambroży T, Rydzik Ł. Risk factors and socioeconomic determinants of falls among older adults. Front Public Health. 2025;13:1571312. https://doi.org/10.3389/fpubh.2025.1571312. PMID: 40182529.
Lin XZ, Meng RL, Peng DD, Li C, Zheng X Y, Xu HF, et al. Cross-sectional study on prevalence and risk factors for falls among the elderly in communities of Guangdong province, China. BMJ Open. 2022;12(11):e062257. https://doi.org/10.1136/bmjopen-2022-062257. PMID: 36375979.
Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth. 2020;125(4):492–504. https://doi.org/10.1016/j.bja.2020.06.063. PMID: 32798069.
Toneto MAS, Mendes PC, Araújo SA. Characterization of the occurrence of fractures in the elderly: an epidemiological study in a public hospital. Cogit Enferm. 2024;29:e94209. https://doi.org/10.1590/ce.v29i0.94209
Locklear T, Kontos J, Brock CA, Holland AB, Hemsath R, Deal A, et al. Inpatient falls: epidemiology, risk assessment, and prevention measures. A narrative review. HCA Healthc J Med. 2024;5(5):517-25. https://doi.org/10.36518/2689-0216.1982. PMID: 39524960.
Abreu DROM, Novaes ES, Oliveira RR, Mathias TAF, Marcon SS. Internação e mortalidade por quedas em idosos no Brasil: análise de tendência. Cien Saude Colet. 2018;23(4):1131–41. https://doi.org/10.1590/1413-81232018234.09962016. PMID: 29694573.
Montero-Odasso M, Van Der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51(9):afac205. https://doi.org/10.1093/ageing/afac205. PMID: 36178003.
André CU, Carvalho MV, organizadores. Cartilha de segurança da pessoa idosa [Internet]. Brasília: CONASS; 2025 [cited 2025 May 18]. 31p. Available from: https://www.conass.org.br/biblioteca/seguranca-da-pessoa-idosa/
Nunes RDQ, Siqueira NR, França SC, Rocha MF, Prado RL, Bessa PRF, et al. Cirurgia de emergência para traumatismo cranioencefálico em pacientes geriátricos. Rev CPAQV. 2024;16(1):1-10. https://doi.org/10.36692/V16N1-61
Gerber K, Iriarte E, Sierra CJ. Multidimensional frailty and traumatic brain injury among older adults: a literature review. Invest Educ Enferm. 2023;41(2):e02. https://doi.org/10.17533/udea.iee.v41n2e02. PMID: 38589320.
Quadros DV, Wachs P, Magalhães AMM, Severo IM, Tavares JP, Dal Pai D. Daily work variability in falls prevention of hospitalized patients: nursing team’s perception. BMC Health Serv Res. 2023;23(1):931. https://doi.org/10.1186/s12913-023-09956-w. PMID: 37653512.
Vanderloo MJ, Evans E, Smith A, Call M, Locke A, Wright H, et al. Exploration of nurses’ experiences related to moral injury: a reflexive thematic analysis of nurse interviews. J Adv Nurs. 2025;81(10):6843-54. https://doi.org/10.1111/jan.16856. PMID: 40008669.
Wei H, Sewell KA, Woody G, Rose MA. The state of the science of nurse work environments in the United States: a systematic review. Int J Nurs Sci. 2018;5(3):287–300. https://doi.org/10.1016/j.ijnss.2018.04.010. PMID: 31406839.
Peduzzi M, Agreli HLF, Silva JAM, Koyama MAH, Fracolli LA, Xyrichis A. Team climate and patients’ perception of primary healthcare attributes in Brazil: a cross-sectional study. J Interprof Care. 2024 Jul-Aug;38(4):705–12. https://doi.org/10.1080/13561820.2024.2351006. PMID: 38755950.
Istrate MI, Forray AI, Ungureanu MI, Mira JJ, Constantinescu SA, Cherecheș RM. Assessing safety culture and second victim experience following adverse events among Romanian nurses: a cross-sectional study. BMC Nurs. 2025 Jan 28;24(1):102. https://doi.org/10.1186/s12912-025-02745-2. PMID: 39875993.
Nason R. Challenges of implementing complexity in healthcare. Healthc Manage Forum. 2023 Nov;36(6):368-72. https://doi.org/10.1177/08404704231191956. PMID: 37544743.
Wright M. A need for systems thinking and the application of (complexity) science in healthcare. Future Healthc J. 2024;11(4):100185. https://doi.org/10.1016/j.fhj.2024.100185. PMID: 39346936.
Tate K, Penconek T, Dias BM, Cummings GG, Bernardes A. Authentic leadership, organizational culture and the effects of hospital quality management practices on quality of care and patient satisfaction. J Adv Nurs. 2023;79(8):3102–14. https://doi.org/10.1111/jan.15663. PMID: 37002558.
Wu AW, Kachalia AB. Creating a “just culture”: More work to be done. J Patient Saf Risk Manag. 2023;28(2):56–8. https://doi.org/10.1177/25160435231168152
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