Patient safety: analysis of the incidents notified in a hospital, in south of Brazil

Abstract

This study aimed to evaluate the incidents reported between the years 2008 and 2012, in a large hospital in southern Brazil. This is a retrospective study of documentary analysis, transverse and descriptive with a quantitative approach. Data was collected in march 2013, analyzed and presented as absolute and relative frequency. We identified 755 cases; this represented 1.1% of total hospitalizations. The higher frequency of reporting in inpatient units was 64.8%. The incident with the highest prevalence in this study was 45.4% falls, followed by medication error 16.7% and 16.2% other incidents. The low number of notifications can be related to the system adopted by the institution where the professional who notifies the incident needs to be identified.

Segurança do paciente na percepção da enfermagem e medicina em unidades de terapia intensiva neonatal

“…It highlighted, for example, the occurrence of adverse events associated with mechanical ventilation, which doubled when the number of neonates per nursing technician was higher than 3.8, and tripled when this ratio achieved 4.8 neonates per nursing technician. The same situation was identified with nurses, in which the risk for adverse events tripled when the number of neonates was higher than 11 per nurse (19) . However, the Brazilian legislation mentions that NICUs must have a minimum team, with an appropriate number of professionals, aiming at the safety of care processes.…”

The practice of reporting adverse events in a teaching hospital

“…Emphasis is placed on the importance of the forms being clear, simple, fast-tracked, and that professionals are advised to complete them with the assurance of confidentiality of the notified information. In addition, the professional must do it anonymously, which increases the confidence of the professionals in reporting (10) . It is also worth noting that despite studies pointing out that the notification can be manual or computerized, one study showed that electronic notification is more advantageous, increasing the quality of the reports between 58.7% and 62%, leading to a reduction in deleted entries, and greater participation of professionals, mainly nursing technicians (14) .…”

“…Considering the presented ideas, we ask: how does the practice of reporting adverse events in the daily life of professionals occur? It is assumed that the notification of incidents is underreported in the reality of the institution, which may be related to the adopted notification system where the professional notifying the incident needs to identify him/herself (10) . This research aims to understand the practice of reporting adverse events by health professionals.…”

Nursing Errors: A Study of the Current Literature

“…Among all the studies analyzed, the greatest emphasis was given to medication errors, [13][14][15][16][17][18][19][20][22][23][29][30][31][32][33][34][35][37][38]40,[42][43] this is due to the choice of studies that recommended analyzing the errors done by the nursing team, who are mainly responsible for this activity. Falls were reported in four studies, but with less incidences.…”