11th EORNA Congress Valencia, Spain | 16 - 18 May 2024 ePosters 88 470 The importance of reporting adverse events in an operating room Ana Sofia Rodrigues1, Maria Manuela Silva2, Silvia Oliveira2 1Serviço Nacional De Saúde, Portugal, 2Hospital de Braga Background: Bearing in mind that “To err is human, to cover up is inexcusable and not to learn from mistakes is unforgivable”, as stated by the WHO Patient Safety representative, Sir Liam Donaldson, the importance of reporting adverse events is highlighted as a strategy to promote a culture of safety for nursing care in all contexts and particularly in the operating theatre. Ugur (2016) is of the opinion that operating theaters, as care units, are one of the areas of health where it is described that failures are frequent. Due to the nature and complexity of the care provided here, the great diversity and number of health professionals who work as a team, conditions are created for adverse events to occur. Analyzing the notifications from the operating theatre, it is clear that it’s underreported and there is still a vast field of opportunities to notify. Therefore, we defined a project to implement a set of actions, which aim to promote an increase of notification of adverse events in the Operating theatre. Objectives: Increase the number of adverse event notifications reportes, in operating theatre, by 50% over a period of 12 months, as a result of the project implementation; Methods: Different methodologies were adopted to promote the reporting of adverse events, namely training, focus groups, dynamic framework and adaptation of the reporting platform. Results: Until December 2023, we recorded a 25% increase in the notification of adverse events. Implemented a dynamic framework to disseminate data and messages to promote adverve events notification. Access to the notification platform outside the hospital is now allowed. Conclusion: Using the proposed methodology, it was interesting to understand the context and develop strategies that contribute to promoting the notification of adverse events, with the goal of creating value and to promote a patient safety culture. 471 Nursing care in pediatric epidural haematoma Encarnacion Beneitez Garcia1, Jaime Reynolds Gutierrez Tena1, Marta Maria Sosa Marin1, Ana Mota1 1Hospital Universitario Infantil Niño Jesus, Operating theatre, Madrid, Spain Background: Epidural haematoma is a blood collection between the duramater and the skull. Intracranial hypertension is produced by the haematoma and if it progresses can lead to brain herniation and death. It requires emergency surgical treatment. Patient’s life depends on the quality of care. Objectives: Developing a guide which describes pediatric surgical specific care, necessary materials, equipment and arrangement in theatre. This should result in new staff easier training, more standardized care and better patient safety. Methods: • Having a close contact with neurosurgeons, anaesthesiologists and specialized nursing staff to clarify the indications, specific materials and equipment arrangement. • Current hospitals documentation on the topic review. • Literature review. Results: Based on the information obtained, we have produced a pediatric pediatric epidural haematoma drainage guide. This results in better quality of care, a unified action criteria and allows for subsequent reassessment. Conclusion: Neurosurgical pediatric procedures require special equipment. Nursing staff must know about it in order to minimize errors and respond in the most effective way possible in an emergency. Implementing epidural haematoma drainage guide facilitates new staff training, minimizes surgical timing, standardizing nursing practices and guarantees safety at work.
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