This study aims to portray the patient's safety interfaces in intensive care in a Brazilian public health institution and the presence of iatrogenies.
This study has an exploratory descriptive approach of qualitative condition; the research was carried out from 2009 to 2010.
The study was carried out in six units, which require intensive care in health, of a large public hospital in the state of Pernambuco.
Of the 163 participants in the qualitative study, thirty-one were nurses, a hundred and ten were nursing technicians and twenty-two were nursing assistants.
This study also highlights the performance deficit in relation to the protocol used in the diet, that 91 (55.8%) health professionals do not perform intensive therapy in diet administration according to the protocols.
Updates and training programs are being developed intensively in the hospital with the purpose of promoting the best functional performance of the employee and maintaining the institution's sustainability in the health market.
In intensive care in Brazil, it is still emphasized that educating the health professional is fundamental to increase the quality of care to the critical patient and, thus, to reduce the negative indicators of iatrogenies.
Iatrogenic, Iatrogenesis, Errors in care, Intensive therapy, Iatrogenic diseases
Iatrogenic conditions are those that result from the intervention of the multidisciplinary health team, whether correct or incorrect, justified or not, but which result in detrimental consequences for the patient's health . Few studies have focused on assessing the risks to patients, especially those hospitalized in emergency and intensive care services, and only in the last decades attention has been drawn to the importance of these problems . Iatrogenic status becomes more important in hospitalized patients in emergencies or intensive care, in which both their incidence and the intensity of their manifestations tend to be more pronounced . In the Hospital of Restoration in Recife/PE, about 4500 hospital records of patients showed that patients hospitalized in critical sectors such as emergency and intensive care centers had twice as high iatrogenic rates as patients with 16-44 years of age . As the care in sectors such as emergencies and intensive care centers has a multidisciplinary character, where professionals from various areas are associated to offer a global assistance to the patient, the concept of iatrogenia in intensive care has a broader meaning, relating to the ducts taken by the various team members . The documentation of iatrogenic complications has been generally unclear and vague, with few hospital services adopting protocols to verify the complications determined by the diagnostic and therapeutic measures adopted . The problematization is far from being solved, on the contrary, it is probable that, for the same reason, it is increasing [4,6-8]. In a simplified way, it is considered that the Brazilian Unified Health System (SUS) proposes a model in which all citizens , irrespective of their socioeconomic condition , are entitled to access the health service and receive care [7-9,11,12] in a hierarchical network according to the complexity of the service . Thus, this study aimed to portray the patient's safety interfaces in intensive care in a Brazilian public health institution and the presence of iatrogenies.
This study has an exploratory descriptive approach of qualitative condition; the research was conducted from 2009 to 2010. In six units, this requires intensive care in health, a large public hospital in the state of Pernambuco/Brazil. The selection of the study sample , in relation to the qualitative and quantitative indicators, had as general characteristic for inclusion in the research the following criteria: Being a health professional (nurse, nursing technician, physiotherapist, physician, nutritionist) away from their duties at the institution's intensive care center, to have a one-year inpatient stay in the facility, since the considerable period of adjustment of the employee to the unit of work would be six months. Exclusion criteria were: Health professionals who presented health leave, maternity leave, premium leave, medical certificate withdrawal and instruments with less than 50% completion. Through the inclusion criteria, 263 health professionals were selected, mainly nurses and nursing technicians from the respective intensive care centers of the public health institution. Still, regarding the qualitative demonstration of the study, health professionals who did not respond to the qualitative block of the instrument were included as exclusion criteria. For quality evaluation data were collected through the direct observation of health professionals and the analysis of medical records and evaluations in hospitalized patients (medical prescription and vital signs check), after presentation of the objectives and ethical aspects to the participant or responsible. Thus, 100 health professionals who did not meet the criteria for inclusion in the study were excluded. Finally, the study represented 163 health professionals for the qualitative cut of the research. The research project was presented to health professionals, in the case a document of acceptance in the participation in the research was delivered signature and consent (Free and Informed Consent Term).
In order to finish due to ethical issues, CNS Resolution n.196/96 of the National Health Council was respected, with submission of the project to the Research Ethics Committee of Hospital da Restauração - PE, a free and informed consent form. The survey was approved under the CAAE n. 0096.0.102.000-09.
Iatrogenesis in any of the processes in intensive care may have very serious consequences , however when the error refers to the identification of the patient [4,14], this negative result can develop a chain of undesirable events , the study reinforces the negative indicators in emphasizing that 89 (54.7%) (Table 1) of the health professionals responsible for intensive care made errors in patient identification , actions further reinforced by error in the barrier method with 82 (50.4%) (Table 1) or in the intensive care center or red wing of major emergencies made the error in the identification  of the patient and errors in the methods used as a barrier to reduce the errors . The study reinforces that the identification of the patient by means  of a bracelet , expresses a greater response  when compared to the procedure done in the bed . It is verified in previous studies  in relation to the identification of the client by bracelet  also does not reach levels of quality considered satisfactory [6,16] since the quality of the assistance in relation to identification  of the patient by bracelet is classified in the same way [7,9], that is, borderline [8,9]. The result of this study highlights  the high number of hospital infection in intensive care 87 (53.3%) (Table 1) as adverse causes and strengthens the error in the accomplishment of the drug therapy , 91 (55.9%) (Table 1) which is presented as a consequence by the absence of nursing systematization 140 (85.9%) (Table 1) very common in Brazil [11,17]. Recently, studies with critically  ill patients hospitalized in intensive care  centers  undergo several invasive procedures , thus making it possible to have a greater risk  for adverse events [6,18] such as infections related to health care . By observing these stratified  data in this study  and another study , a response can be obtained [9,11].
Table 1: Evaluation of the iatrogenic elements of the process teaching theoretical learning in intensive care in the process of updating and training in intensive care from the perspective of the health professional (n = 163). View Table 1
Gadelha, et al.  when conducting research in an intensive care  unit in the state of Acre  reported that among the main drugs that were related to adverse events , in this case, antimicrobials  were at the top in related errors in drug therapy , a study conducted by Bohomol  in the city of São Paulo [6,12] also showed the same statistical results , where antibiotics [7,8] were the drugs involved in greater errors . Still, Ramos [9,12] strengthens the current study by affirming in a previous study carried out in the city of Recife , the highlighted drug errors , such as: Incorrect dilutions of drugs , for example, antibiotics 70 (26.7%) (Table 2), administration of drugs in the wrong patient 60 (23%) [9,11] error in the calculation of the dose to be administered, mainly vasodilators and antibiotic therapy totaling 43 (16.7%)  of health professionals  specifically nursing (10%) thus evidencing  the increase in hospital infections  due to iatrogenies performed  in the drug therapy  process . In order to avoid errors in drug therapy  protocols should be developed aiming  at the necessity of drug therapy [4,9] for example for the medication to be administered correctly [7,8], one must observe the validity , time of the medication  emphasize the importance of the patient's name [7,9] correct dilution [8,12] and the need to administer this medication  according to the correct technique for the purpose  of a quality of care , and to reinforce the importance of identifying and recording errors  because in this way it is possible to perform actions that allow an update of the correct procedures [9,11,13].
Table 2: Assessment of risk factors that interfere in patient safety in intensive care (n = 163). View Table 2
It is noteworthy that  amidst the adversities presented when granting a patient care [15,19] scientific knowledge  becomes very important  when it comes to preventing technical failure [1,9,12] and this error can be life-threatening  but it becomes very important the ethical conduct  that the professional will express  and learn from mistakes not neglecting  and/or under-reporting cases . Similarly, Padilha  in one study obtained three concepts  to carry out this evaluation process of continuous improvement  in order to prevent a reduction in damages  which first confers the structure of available resources to establish quality assistance  the second refers to the managerial process  that is how the use of resources is being carried out and significantly the latter is aimed at emphasizing  the assistance in being carried out in an appropriate and correct way .
However, when analyzing our data , we observed some shortcomings in the quality process in relation to iatrogenic events  which are caused by the interventions of health professionals  be it nursing or physicians , physiotherapy and others  and are not explained by underlying diseases .
These events tend to aggravate [4,10] the patient and increase the length  of stay in intensive care [20,21] so the negative indicator  will be the hospital  stay and the increase in the cost of hospitalization .
The only reported data evidencing this profile  was carried out in 1992  and published in 1998  by McQuillan  in this case this study elaborated a management of oxygen therapy [9,12] airways  respiration and circulation  added to the monitoring before the patient's admission period in the intensive care unit [6,19] parallel to the opportunity of admission  and it was observed that care was lower in 54% of the patients [9,12]. Paralleling other studies in the USA and France  it has reported that in the last 20 years  between 1% and 20% of intensive care  admissions are associated with an iatrogenic event .
When it is essential to do the root cause analysis [7,10] for example where the problem will be carried out in the methodological  execution in the detection  of the primary causes  it is observed that the recurrences of iatrogenies/adverse events [9,12].
In this way, those responsible  for this process need to establish follow-up and results indicators  in the recommendations  in addition to reporting without underreporting  the data . For example, the heads of intensive care  centers and the entire professional body must be involved in the process  as they are the executors  of most of the recommendations .
Table 2 reinforces the importance of safety , although it is not the guarantee of fully qualified care  nevertheless, it is one of the pillars that underlies health quality [7,8] since the risks associated with care in this sector  in the case in intensive care units . Analyzing Table 2, it is possible to verify important  measures for good quality  in patient care .
Usually the procedures [10,17] are being performed following some protocols  focused on the safety [12,14] of the patient and health professional  and has been used in a preventive way  that is to minimize the damages to the patient the institution performs care  based in criteria of institutional protocols  through techniques with the objective  of providing quality care  thus avoiding intercurrences or severity  of the patient in intensive care . In order to minimize the occurrence of adverse events  we can positively highlight the prevention  of falls where it is performed  by the majority of the participants 107 (65.6%) (Table 2) through specific use of standardized protocols  aimed at reducing the indicators negative  in intensive care related to fall , it is observed that with these data  it is noticed that the identification of factors predisposing  to fall as incapacity of muscle control in the bed  age and drug treatments is important for the reduction  of negative indicators  in relation to quality care provided in intensive care .
The Ministry of Health , with the objective of reducing falls numbers  has launched the "protocol for fall prevention"  containing instructions to guide  the professionals in their care  and all have the necessary technical knowledge to its application  however, the use of other now structural measures  become important and of great help for an improvement in the quality  of this assistance  thus avoiding falls-related iatrogenies .
In addition to the use of protocols  it is necessary to maintain a constant reassessment of intensive care assistance  for example the need for use in new technologies in intensive care assistance  as from investments in the hospital  especially in intensive care centers  useful for the prevention of unfavorable fall-related indicators . Another positive point that we can highlight  is the use of protocol in surgical procedures where 114 (69.9%) (Table 2) of the respondents answered  that they use as a way to guarantee a safe surgery . Its use is promising and guarantees  the patient's follow-up during their hospitalization for surgery .
However, the use of all protocols for the prevention  of adverse events becomes important in an intensive care unit  simple measures such as hand washing were among the least used protocols  by participants where 126 (77.3%) (Table 2) reported reduce performing hand washing as established .
It is known  that the hand is a means of transport for several pathogens [9,14] and it is transmitted to other people through direct contact with the hand  or some material that has been contaminated by the hand [4,9]. The most effective method for the prevention  of cross-contamination is hand washing [8,14] which is the responsibility of the individuality of each professional .
In a previous study, Padilha  reports that the vast majority of professionals do not perform hand washing prior to the procedures to be performed  only after the procedure does the routine of washing and even to this low adherence  the author highlights the lack  of knowledge of the health professional regarding hand washing [9,11].
This negative index demonstrates as presented  in our study the lack of adherence to the method that best prevents cross infection . However, Bohomoll  has a positive statement regarding  the education of health professionals  since educating  the health professional  is a form of stimulation for hand washing  and encourages the highest adhesion index .
This study also highlights  the performance deficit in relation to the protocol  used in diet care, which 91 (55.8%) health professionals do not perform intensive care  in the administration  of diet according to the protocols .
It is worth mentioning that dietary administration  can be performed in the intensive care of the following enteral routes : Nasoentérica , oroentérica , jejunostomy , gastronomy  or venous  called parenteral route  the importance of care is reinforced and it becomes  important for caregivers to have the necessary knowledge  to administer the diet and to be able to observe the patient's capacity  regarding their clinical aspect and their limitations .
As discussed previously in Table 1 and statistically reinforced by Table 2, the reported difficulty in performing drug therapy is high , this study presented an index of 115 (70.5%) (Table 2) but at the same time that this difficulty is shown present  the lack of adherence to measures  due to the use of protocols in drug administration is of concern in our studies .
Ramos  makes it clear in both researches  that for prevention it is necessary to "prevent"  that is, it refers to looking forward , to the future , specifically  in technical-scientific knowledge  is made necessary for the purpose of being able to carry out interventions that could occur if the updating  or qualification of the team becomes important for the preparation, thus avoiding iatrogenic causes .
Updates and training  of the health team should be approached as a strategy to reduce  adverse events and be continuous . However, public hospitals suffer  daily with high demand for financial resources and employee turnover .
As an alternative to in-hospital education  the use of an online teaching platform  a form of educational assistive technology  which professionals can obtain as an alternative to updating .
In this study the knowledge deficit of health professionals in relation to iatrogenies was identified and how to prevent, and it was highlighted the low adherence in the techniques of hand hygiene.
In contrast, positive indicators in nursing intensive care in patient safety were highlighted in relation to the use of care protocols, such as prevention of falls. It is worth emphasizing that research on patient safety in Brazil is on the rise, so this study proposes a reflection on the identification and dissemination of iatrogenies in a constructive way in the care and thus use tools to improve patient safety and encourage new studies in the intensive care in Brazil.
Restoration Hospital - Pernambuco - Brazil.
Federal University of Mato Grosso do Sul.