Comunicação e (IN) segurança do paciente em unidades de terapia intensiva pediátrica

• Autor(a) principal: Valera, Ingrid Mayara Almeida
• Data de Publicação: 2016
• Tipo de documento: Dissertação
• Idioma: por
• Título da fonte: Repositório Institucional da Universidade Estadual de Maringá (RI-UEM)
• Texto Completo: http://repositorio.uem.br:8080/jspui/handle/1/2344
• topic: Enfermagem pediátrica; Unidade de Terapia Intensiva; Segurança do paciente; Comunicação; Troca de informação; Comunicação; Registros de enfermagem; Brasil.; Communication; Information exchange; Nursing records; Patient safety; Intensive care; Pediatric nursing; Brasil.; Ciências da Saúde; Enfermagem

Communication failures in nursing, particularly among the nurses, could result in potential damage to the professional, to the institution, but mostly the safety of patients/clients. In this context, Shift Change (SC) and nursing records may be considered as essential tools for quality of care and patient safety. This descriptive study with a quantitative approach was carried out between May and December 2015 and aimed to analyze two ways of communication from the Pediatric nursing staff in the Intensive Care Unit of Paraná. Data were collected through non-participant observation from the SC of the nursing team and a documentary research in the nursing records of patients in three public university hospitals in the Northwest, West, and East region of Paraná State. Data were presented in tables on electronic spreadsheets Microsoft® Office Excel 2010® software and analyzed using descriptive statistics, with absolute and relative frequencies. The results were discussed based on literature about communication issues in the shift change, nursing records, and patient safety. There were 54 general SC observed. Among them, in 41 SC (75.9%), nursing professionals used a verbal method without written notes; only in 13 SC (24.1%) there was participation of caregivers; in 29 SC (53.7%) there was at least one interruption caused mainly by delays of nursing staff (65.5%). There were also 204 SC observed individually conducted, that is, for each patient, noting that: in 31 SC (15.2%) there was no identification of patients by nursing professionals; in 54 (26.5%) there was no transmission of information related to medicines administered during their work shift. Concerning the documentary research, 92 nursing records of patients were analyzed. In them, it was found that in only 68 (73.9%) there were complete identification of the nurse who carried it out; in 61 (66.3%), the information is presented completely legible; in 20 (21.8%),there was at least one erasure; 90 (97.8%) had abbreviations/acronyms standardized, and complete date and time. It is concluded that the communication of the nursing staff through the shift change and nursing records was in general, adequate to the literature, but it is necessary to improve, especially in aspects related to method or procedure type; the participation of caregivers, interruptions, patient identification, identification of the professional who performs the records, legibility of information recorded and; minimization/absence of erasures.