Root cause qualitative analysis of acute childhood poisonings as a study of sentinel surveillance

Main Article Content

Mirella Machado Ortiz Modesto
https://orcid.org/0000-0002-2635-3184
Paola Kallyana Guarneri Carvalho de Lima
https://orcid.org/0000-0003-0781-5926
Aroldo Gavioli
https://orcid.org/0000-0003-1454-1652
Anai Adari Hungaro
Gabriel da Silva Modesto
Adriana Valongo Zani
Sônia Silva Marcon
Magda Lúcia Félix de Oliveira
https://orcid.org/0000-0003-4095-9382

Abstract

Objective: To analyze the root cause of occurrences of severe intoxication in children and adolescents from the perspective of sentinel events. Methods: Observational, retrospective, and qualitative study of a series of cases of seven children and young people with a confirmed clinical picture of intoxication by various agents, treated in a stabilization room of emergency care units or intensive care, and notified to toxicological information and assistance center from January to June 2019. The epidemiological surveillance of sentinel events was used based on a review of hospital documents and in-depth interviews with family members. The Root Cause Analysis (RCA) matrix was used to evaluate the cases and the systematic reconstruction of the cases' antecedents.Results: The age profile of the study population, the pattern of agents and substances involved - poisoning by intentional ingestion in five (71%) cases, indicated critical points and missed opportunities for prevention. The individual and family history analysis indicated as direct causal factors the deviations from norms for preventing poisoning at home or in the family context for all cases.The prevention and health promotion activities in the health services constituted the underlying causes of the occurrences.Conclusion: The root cause analysis identified a deficiency in public policies, but the interface between education, public security, social assistance, economy, and health policies would be preponderant for preventing childhood and youth poisoning.



Article Details

How to Cite
1.
Modesto MMO, Carvalho de Lima PKG, Gavioli A, Hungaro AA, Modesto G da S, Zani AV, Marcon SS, de Oliveira MLF. Root cause qualitative analysis of acute childhood poisonings as a study of sentinel surveillance . Health Sci J [Internet]. 2022Mar.28 [cited 2024Mar.29];12(1):24-0. Available from: https://portalrcs.hcitajuba.org.br/index.php/rcsfmit_zero/article/view/1183
Section
ORIGINAL ARTICLE
Author Biographies

Mirella Machado Ortiz Modesto, Postgraduate Program in Nursing, State University of Maringá (UEM)

Nurse, Doctoral Student in Nursing, Master in Nursing from the State University of Maringá.

Paola Kallyana Guarneri Carvalho de Lima, Postgraduate Program in Nursing, State University of Maringá (UEM)

Nurse, Doctoral Student in Nursing, Master in Nursing from the State University of Maringá.

Aroldo Gavioli, Postgraduate Program in Nursing, State University of Maringá (UEM)

Nurse, Doctoral Student in Nursing, Master in Nursing from the State University of Maringá.

Anai Adari Hungaro, Postgraduate Program in Nursing, State University of Maringá (UEM)

Nurse, Doctor in Nursing, Master in Nursing from the State University of Maringá.

Gabriel da Silva Modesto, Department of Physical Education, State University of Maringá (UEM)

Graduating in Physical Education at the State University of Maringá.

Adriana Valongo Zani, Postgraduate Program in Nursing, State University of Londrina (UEL)

Adjunct Professor of the Graduate Program in Master's and Doctoral Nursing at the Health Sciences Center at the State University of Londrina.

Sônia Silva Marcon, Postgraduate Program in Nursing, State University of Maringá (UEM)

Full Professor at the Nursing Department at the State University of Maringá

Magda Lúcia Félix de Oliveira, Postgraduate Program in Nursing, State University of Maringá (UEM)

Adjunct Professor at the State University of Maringá.

References

1. Nistor N, Frasinariu OE, Rugina A, Ciomaga IM, Jitareanu C, Ştreanga V. Epidemiological study on accidental poisonings in children from northeast Romania. Medicine (United States). 2018;97(29):e11469. https://doi.org/10.1097/MD.0000000000011469
2. Zhang Y, Yu B, Wang N, Li T. Acute poisoning in Shenyang, China: a retrospective and descriptive study from 2012 to 2016. BMJ Open. 2018;8:21881. https://doi.org/10.1136/bmjopen-2018-021881
3. Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. Sistema Nacional de Informações Tóxico-Farmacológicas (SINITOX). Casos registrados de intoxicação humana e envenenamento: região Centro-Oeste. Rio de Janeiro: Fiocruz. 2017 [cited 2022 Feb 25]. Available from: https://bit.ly/3heTCTx
4. Lee VR, Connolly M, Calello DP. Pediatric poisoning by ingestion: developmental overview and synopsis of national trends. Pediatr Ann. 2017;46(12):e443-8. https://doi.org/10.3928/19382359-20171121-01
5. Sales CCF, Suguyama P, Guedes MRJ, Borghesan NBA, Higarashi IH, Oliveira MLF de. Intoxicação na primeira infância: socorros domiciliares realizados por adultos. Rev Baiana Enferm [Internet]. 2017 [cited 2022 Feb 25];31(4):e23766. Avaiable from: https://bit.ly/3pfB2zj
6. Brito JG, Martins CB. Intoxicação acidental na população infantojuvenil em ambiente domiciliar: perfil dos atendimentos de emergência. Rev Esc Enferm USP. 2015;49(3):373-80. https://doi.org/10.1590/S0080-623420150000300003
7. Costa AO, Alonzo HGA. Centros de Informação e Assistência Toxicológica no Brasil: descrição preliminar sobre sua organização e funções. Saúde em Debate. 2019;43(120):110-21. https://doi.org/10.1590/0103-1104201912008
8. Boletim Epidemiológico Secretaria de Vigilância em Saúde − Ministério da Saúde. 1969;
9. Santana CJ, Silvino MCS, Rosa NM, Almeida EG, Margarete dos Reis L, Oliveira MGF. Potencialidade de um evento sentinela para vigilância epidemiológica do abuso de drogas. Rev enferm UFPE on line. 2014 [cited 2022 Feb 25];8(12):4337-81. Avaiable from: https://bit.ly/3JY0bGj
10. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP. Sentinel Health Events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health. 1983;73(9):1054-62. https://doi.org/10.2105/ajph.73.9.1054
11. Pena MM, Melleiro MM. O método de análise de causa raiz para a investigação de eventos adversos. Revista de Enfermagem UFPE on line. 2017;11(12):5297. https://doi.org/10.5205/1981-8963-v11i12a25092p5297-5304-2017
12. Cardoso Alux Teixeira T, Helena de Bortoli Cassiani S. Root cause analysis of falling accidents and medication errors in hospital. Acta Paul Enferm. 2014;27(2):100-7. https://doi.org/10.1590/1982-0194201400019
13. Brasil. Casa Civil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências [Internet]. [cited 2022 Feb 25]. Available from: http://www.planalto.gov.br/ccivil_03/leis/l8069.htm
14. Brasil. Lei no. 12.852, de 5 de agosto de 2013. Institui o Estatuto da Juventude e dispõe sobre os direitos dos jovens, os princípios e diretrizes das políticas públicas de juventude e o Sistema Nacional de Juventude – SINAJUVE [Internet]. 2013 [cited 2022 Feb 25]. Avaiable from: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2013/lei/l12852.htm
15. Rocha RRM, França AFO, Zilly A, Caldeira S, Machineski GG, Silva RMM. Conhecimento e perspectiva de enfermeiros na rede de atenção materna e infantil do Paraná. Cienc Cuid Saude. 2018;17(1):39235. https://doi.org/10.4025/cienccuidsaude.v17i1.39235
16. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 35th Annual Report. Clinical toxicology (Philadelphia, Pa) [Internet]. 2018 [cited 2021 Jul 14];56(12):1213-415. https://doi.org/10.1080/15563650.2018.1533727
17. Brito JG, Martins CBG. Accidental intoxication of the infant-juvenile population in households: Profiles of emergency care. Rev Esc Enferm USP. 2015;49(3):372-9. https://doi.org/10.1590/S0080-623420150000300003
18. Domingos SM, Borghesan NBA, Merino MFGL, Higarashi IH. Internações por intoxicação de crianças de zero a 14 anos em hospital de ensino no Sul do Brasil, 2006-2011. Epidemiol Serv Saúde. 2016;25(2):343-50. https://doi.org/10.5123/S1679-49742016000200013
19. Maior MCLS, Osorio-de-Castro CGS, Andrade CLT. Internações por intoxicações medicamentosas em crianças menores de cinco anos no Brasil, 2003-2012. Epidemiol Serv Saúde. 2017;26(4):771-82. https://doi.org/10.5123/S1679-49742017000400009
20. Joshi SV, Hartley SN, Kessier M, Barstead M. School-based suicide prevention: content, process, and the role of trusted adults and peers. Child and adolescent psychiatric clinics of North America. 2015;24(2):353-70. https://doi.org/10.1016/j.chc.2014.12.003
21. Sánchez-Teruel D, Muela-Martínez JA, García-León A. Variables de riesgo y protección relacionadas con la tentativa de suicidio. RPPC. 2019;23(3):221-9. https://doi.org/10.5944/rppc.vol.23.num.3.2018.19106
22. Mishra KK, Gupta N, Bhabulkar S. Sociodemographic profile of suicide attempters among the rural agrarian community of central India. Ind Psychiatry J. 2015;24(2):185-8. https://doi.org/10.4103/0972-6748.181720
23. Nie LH, Wright RO, Bellinger DC, Hussain J, Amarasiriwardena C, Chettle DR, et al. Blood lead levels and cumulative blood lead index (CBLI) as predictors of late neurodevelopment in lead poisoned children. Biomarkers. 2011;16(6):517-24. https://doi.org/10.3109/1354750X.2011.604133
24. World Health Organization. Poisoning Prevention and Management. Definitions. Geneva: WHO, 2016 [cited 2022 Feb 25]. Available from: https://bit.ly/3M0ZnCB
25. Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A, Neacsiu AD, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder. A randomized clinical trial and component analysis. JAMA Psychiatry. 2015;72(5):475-82. https://doi.org/10.1001/jamapsychiatry.2014.3039
26. Prüss-Ustün A, Vickers C, Haefliger P, Bertollini R. Knowns and unknowns on burden of disease due to chemicals: a systematic review. Environ Health. 2011;10:9. https://doi.org/10.1186/1476-069X-10-9
27. Santos LA, Kind L. Comprehensive care, intersectoral action and healthcare: Paths to face suicide. Interface. 2020;24:e190116. https://doi.org/10.1590/interface.190116
28. Fortaleza, Instituto Doutor José Frota. Alburquerque PLMM (org). Intoxicações agudas: guia prático para o tratamento. Fortaleza: Soneto Editora, 2017 [cited 2022 Feb 25]. 200 p. Available from: https://bit.ly/3vcxHVo
29. Amorim MLP, Mello MJG, Siqueira MT. Poisoning in children and adolescents notified at a toxicology center in the Northeast of Brazil. Rev Bras Saude Mater Infant. 2017;17(4):765-72. https://doi.org/10.1590/1806-93042017000400009
30. Brahmbhatt K, Grupp-Phelan J. Parent-adolescent agreement about adolescent's suicidal thoughts: a divergence. Pediatrics. 2019;143(2):e20183071. https://doi.org/10.1542/peds.2018-3071
31. Vilaça L, Volpe FM, Ladeira RM. Accidental poisoning in children and adolescents admitted to a referral toxicology department of a Brazilian emergency hospital. Rev Paul Pediatr. 2020;38:e2018096. https://doi.org/10.1590/1984-0462/2020/38/2018096