Incidents and adverse events notified at hospital level




Patient Safety; Notification; Delivery of Health Care.


Objective: to identify the incidents and adverse events notified in a large size hospital. Methods: a retrospective study was carried out based on data extracted from handwritten notifications sheets, made available by the Patient Safety Nucleus of a large size hospital. The following variables were analyzed: type of incident, according to international safety goals; severity of the incidents with damage; and measures proposed to minimize the effects of the notified incident. Results: among the 1167 notifications, 653 (66.8%) of the incidents were related to pharmacovigilance, 563 (48.6%) presented as potential harm, 355 (28.7%) caused harm to the patient and of these, 228 (68.0%) were of mild intensity. Proposed actions were described in 705 (60.4%) of the notifications. Conclusion: the notifications allowed identifying a high number of incidents with potential to cause harm, denoting failures that could be minimized with the implementation of institutional protocols and professional training.


Panattieri ND, Dackiewicz N, Arpí L, Godio C, Andión E, Negrette C, et al. Consenso: seguridade del paciente y las metas internacionales/Patient safety and the international goals: Consensus document. Arch Argent Pediatr. 2019; 117(6):277-309. doi:

Silva TO, Bezerra ALQ, Paranaguá TTB, Teixeira CC. Patient involvement in the safety of care: an integrative review. Rev Eletr Enf. 2016; 18:e1173. doi:

Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Qual Saf. 2016; 25(2):92-9. doi:

Williams GD, Muffly MK, Mendoza JM, Wixson N, Leong K, Claure RE. Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children’s hospital: targeted interventions to increase the rate of reporting. Anesth Analg. 2017; 125(5):1515-23. doi:

Jämsä JO, Palojoki SH, Lehtonen L, Tapper AM. Differences between serious and nonserious patient safety incidents in the largest hospital district in Finland. J Healthc Risk Manag. 2018; 38(2):27-35. doi:

Duarte SCM, Stipp MAC, Silva MM, Oliveira FT. Adverse events and safety in nursing care. Rev Bras Enferm. 2015; 68(1):144-54. doi:

World Health Organization. The conceptual framework for the international classification for patient safety. Version 1.1. Final Technical Report [Internet]. 2009 [cited Jan 11, 2020]. Available from:

Furini ACA, Nunes AA, Dallora MELV. Notifications of adverse events: characterization of the events that occurred in a hospital complex. Rev Gaúcha Enferm. 2019; 40:e20180317. doi:

Bezerra WR, Bezerra ALQ, Paranaguá TTB, Bernardes MJC, Teixeira CC. Occurrence of incidents at a surgical center: a documentary study. Rev Eletr Enf. 2015; 17(4). doi:

Pelzang R, Hutchinson AM. Patient safety policies, guidelines, and protocols in Bhutan. Int J Health Plann Manage. 2019; 34(2):491-500. doi:

Ramasethu J. Prevention and treatment of neonatal nosocomial infections. Matern Health Neonatol Perinatol. 2017; 3:5. doi:

Thomas D, Pavic A, Bisaccia E, Grotts J. Validation of fall risk assessment specific to the inpatient rehabilitation facility setting. Rehabil Nurs. 2016; 41(5):253-9. doi:

Basile LC, Santos A, Stelzer LB, Alves RC, Fontes CMB, Borgato MH, et al. Incident analysis occurrence related to potentially dangerous medicines distributed in teaching hospital. Rev Gaúcha Enferm. 2019; 40:e20180220. doi:

Hoefel HHK, Echer I, Lucena AF, Mantovani VM. Incidentes de segurança ocorridos com pacientes durante o cuidado de enfermagem. Rev Epidemiol Control Infec. 2017; 7(3):174-80. doi:

Núñez PG, Barrios MDS, Álvarez MCV, Delgado RC, Lorenzo JCA, González PA. Results of provisional use of a system for voluntary anonymous reporting of incidents that threaten patient safety in the emergency medical services of Asturias. Emergencias [Internet]. 2016 [cited Apr 13, 2020]; 28(3):146-52. Available from:



How to Cite

Mascarello, A., Massaroli, A., Pitilin, E. de B., Araújo, J. S., Rodrigues, M. E., & Souza, J. B. de. (2021). Incidents and adverse events notified at hospital level. Rev Rene, 22, e60001.



Research Article

Most read articles by the same author(s)