[Procedure adverse events: nursing care in central venous catheter fracture].
In a intensive care unit (ICU) there are many factors that can lead to the occurrence of adverse events. A high percentage of these events are associated with the administration of drugs. Diagnostic tests, such as computed tomography, is common in critically ill patients and technique can be performed with injection of contrast agent to enhance the visualization of soft tissue. The contrast is a medication and the nurse is responsible for its proper administration. The management of the critically ill patient is complex. ICU team and radiology shares responsibility for the care and safety of the patient safety during the transfer and performing tests with contrast. The World Health Organisation patient safety strategies, recommends analysing errors and learning from them. Therefore, it was decided to investigate the causes of the category E severity adverse events that occurred in a patient who was admitted to the ICU for septic shock of abdominal origin. An abdominal computed tomography was performed with contrast which was injected through a central venous catheter. The contrast did not appear in the image. What happened? Causal analysis helped to understand what triggered the event. A care plan and an algorithm were drafted to prevent it from happening again, with the following objectives: improving knowledge, skills and promoting positive attitudes towards patient safety, working at primary, secondary and tertiary care levels.
Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, España. Electronic address: eva.perez@ssib.es.
Eva
E
Pérez-Juan
Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, España.
Mònica
M
Maqueda-Palau
Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, España.
Cristina
C
Romero-Grilo
Unidad de Cuidados Intensivos, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, España.
Yolanda
Y
Muñoz-Moles
D002405:Catheterization, Central Venous / Q000295:instrumentation* / Q000451:nursing*; D062905:Central Venous Catheters; D004868:Equipment Failure; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged
Accident prevention; Atención de enfermería; Catheter obstruction; Nursing care; Obstrucción del catéter; Patient safety; Prevención de accidentes; Seguridad del paciente