Open AccessIncidents and adverse events notified at hospital level
Author(s) -
Andréia Mascarello,
Aline Massaroli,
Érica de Brito Pitilin,
Jeferson Santos Araújo,
Maria Rodrigues,
Jeane Barros de Souza
Publication year - 2021
Publication title -
rev rene
Language(s) - English
Resource type - Journals
eISSN - 2175-6783
pISSN - 1517-3852
DOI - 10.15253/2175-6783.20212260001
Subject(s) - harm , pharmacovigilance , medical emergency , medicine , adverse effect , incident report , patient safety , emergency medicine , computer security , computer science , psychology , health care , social psychology , economics , economic growth
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.