Accuracy and completeness of records of adverse events through interface terminology

• Published in: Revista da Escola de Enfermagem da U S P
• Main Authors: González Samartino, Maribel, Delgado-Hito, Pilar, Adamuz Tomás, Jordi, Viso Cano, Maria Fe, Castellà Creus, Mònica, Juvé Udina, Eulàlia
• Format: Journal Article
• Language: English
• Published: Universidade de São Paulo 01-01-2018
• Subjects: Bedsores; Infermeria quirúrgica; Pneumonia; Pneumònia; Surgical nursing; Úlcera per pressió
• ISSN: 0080-6234

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.