Incidentes e eventos adversos notificados em um hospital de grande porte

Abstract

Patient safety has been a topic discussed worldwide in health institutions and the reporting of adverse events is one of the main indicators applied to assess the quality of care provided. Health services are increasingly concerned with adopting policies that promote patient safety, so reporting of incidents and/or adverse events is critical to knowledge of the cause in order to create preventive interventions, ensuring thus quality assistance. Thus, this study presented the following research question: which incidents/adverse events were reported in a large hospital. Objective: Given the above, this paper aims to analyze the incidents and/or adverse events reported in a large hospital. Method: This is a study with quantitative approach cross-sectional, retrospective, based on documentary analysis of data that were extracted through consultation of handwritten notification sheets of incidents and/or adverse events from January 2017 to December 2018, available from the Hospital Patient Safety Center. The analysis will take place after data processing using Microsoft Office Excel software. The variables analyzed will be classified according to the type of incident, analysis of incidents according to the six international patient safety goals, classification of the severity of incidents with damage and proposed measures to prevent recurrences of non-conformities. According to the study of the variables, the data will be analyzed descriptively, presented through tables and graphs. Numerical variables will be described as means and standard deviations. Ethical aspects will be respected according to the Resolution on Human Research, Resolution 466/12, of the National Health Council of Brazil. The project was approved by the Research Ethics Committee (CEP) of the researched institution, under Opinion No. 2,621,561 and CAAE No. 85960518.0.0000.5564, on 04/25/2018. Results: A total of 1167 notifications were analyzed, with a gradual increase in notifications over the period investigated, although there is a low rate of notifications made when the complexity of hospital care is associated. The most reported incidents were those related to pharmacovigilance (55, 97%). As well, the outstanding International Patient Safety Goal was to improve drug safety, (68.09%) then reduce the risk of infection (15,23%). Notifications were classified according to the type of incident, highlighting potential damage (48.64%), adverse circumstance (13.88%), and severity 355 events caused harm to the patient, most of them mild (68.05%). Proposed actions to prevent recurrence of incidents were described in (60.41%) of the notifications analyzed. The measures adopted by the Patient Safety Center were: perform an intervention to minimize the incident (20.99%), followed by guidance (18.16%). Conclusion: Notification of incidents can broaden the perception of health professionals regarding the impact of their actions and understand the risk factors involved, as well as develop strategies to avoid its repetition.