title: Nursing care adverse events at an intensive care unit.
abstract: OBJECTIVE
  The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit.
  
  
  METHODS
  Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay.
  
  
  RESULTS
  Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses.
  
  
  CONCLUSIONS
  The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.
authors.affiliation: Departamento de Enfermagem Especializada, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil.
authors.forename: Lucia Marinilza
authors.initials: LM
authors.lastname: Beccaria
authors.affiliation: Departamento de Enfermagem Especializada, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil.
authors.forename: Roseli Aparecida Matheus
authors.initials: RA
authors.lastname: Pereira
authors.affiliation: Departamento de Enfermagem Especializada, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil.
authors.forename: Lígia Márcia
authors.initials: LM
authors.lastname: Contrin
authors.affiliation: Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil.
authors.forename: Suzana Margareth Ajeje
authors.initials: SM
authors.lastname: Lobo
authors.affiliation: Hospital de Base da Fundação Regional de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil.
authors.forename: Diene Henri Longui
authors.initials: DH
authors.lastname: Trajano