Incidents and adverse events notified at hospital level

Andreia Mascarello; Aline Massaroli; Erica de Brito Pitilin; Jeferson Santos Araújo; Maria Eduarda Rodrigues; Jeane Barros de Souza

doi:10.15253/2175-6783.20212260001

Authors

Andreia Mascarello Universidade Federal da Fronteira Sul https://orcid.org/0000-0003-1268-6241
Aline Massaroli Universidade Federal da Fronteira Sul https://orcid.org/0000-0003-4779-5579
Erica de Brito Pitilin Universidade Federal da Fronteira Sul https://orcid.org/0000-0003-3950-2633
Jeferson Santos Araújo Universidade Federal da Fronteira Sul https://orcid.org/0000-0003-3311-8446
Maria Eduarda Rodrigues Universidade Federal da Fronteira Sul https://orcid.org/0000-0002-0770-0670
Jeane Barros de Souza Universidade Federal da Fronteira Sul https://orcid.org/0000-0002-0512-9765

DOI:

https://doi.org/10.15253/2175-6783.20212260001

Keywords:

Patient Safety; Notification; Delivery of Health Care.

Abstract

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.

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