National Patient Safety Program in Brazil: Incidents Reported Between 2014 and 2017

Abstract

Method: A documentary study that used the records of the incidents published in the Reports of Adverse Events (AE) in Brazil. The following variables were selected: number of incidents by type, type of health service, hospital unit, and degree of harm. To find whether there was a significant difference across the Brazilian regions by notifications related to general incidents, AE, and deaths, the analysis of variance and the Tukey tests were used.Results: A total of 109,082 incidents were reported, of which 75,088 were AE, with 649 deaths. In relation to the types of incidents reported, there was a higher frequency in the categories other (30.04%) and failures during health care (26.72%). A total of 93.90% of the incidents occurred in hospitals, with 54,950 cases registered in hospitalization units and 30,141 cases in intensive care units. Statistically significant differences across the Brazilian regions were observed in the number of incidents (P = 0.004), AE (P = 0.004), and deaths (P = 0.024).Conclusions: A significant underreporting of incidents was found in Brazil, demonstrating only the tip of a giant iceberg. More than half of the incidents were reported as AE and were registered in hospitals, reiterating the importance of establishing public health policies at national, state, and municipal levels, with adequate supervision of the health service regarding the implementation of the Patient Safety Nuclei and the preparation of new protocols based on the most prevalent incidents.

Challenges to the consolidation of pharmacovigilance practices in Brazil: limitations of the hospital pharmacist

“…Regarding these concerns, Faustino et al claim that more effective public policies, with the creation of indicators that should be closely monitored by health agencies, or on-site supervision of the development of such activities, may constitute a good response to the reported difficulties. 18 Thereby, we can highlight through our results the need to improve public policies that should reach undergraduate and graduate programs in healthcare, especially among pharmacists, since the majority of the population of this study were enrolled in a graduate program and numerous difficulties were reported related to professional training.…”

“…8,10 From this period to date, pharmacovigilance in Brazil has focused on notification; 10 however, it has not been proved to have a direct impact on patient care yet. 18 Although there is a surveillance network for medicine and a small production and dissemination of information to healthcare professionals about the health risk for some medicines, there is no effective monitoring of the notified events at national level or any responses that may directly impact the patient involved. 10 In addition to these findings from the literature, the reporting rates in Brazil are still lower than the rates foreseen by the global regulatory agencies.…”

Patient safety in primary health care and polypharmacy: cross-sectional survey among patients with chronic diseases

“…However, it imposes, in particular on the pharmacist, the need to advance in the qualification of the care offered to drugs users. In addition, the Ministry of Health establishes the National Patient Safety Program, and in 2017, within this Program established Safety Protocol in the prescription, use and administration of drugs ( 11 ) .…”

Estratégias para apoiar profissionais de saúde na condição de segunda vítima: uma revisão de escopo

“…Com base no exposto, é inquestionável que os EA afetem seriamente a qualidade do cuidado e a segurança do paciente, sendo indispensável a adoção de medidas para reduzir estas ocorrências (Faustino et al, 2018).…”