Patient safety : adverse events notified in the southern region of Brazil, 2014-2019

Abstract

Introduction: One in ten inpatients suffers damage from healthcare, most of which is preventable. Objective: To describe the occurrence and characteristics of adverse events or incidents recorded in the National Health Surveillance System (Notivisa) for the three southern states of Brazil, between March 2014 and January 2019. Methods: Use of data from Notivisa's Adverse Events Reports for the three states of the Brazilian South Region (n=55.536 records). Variables studied: type of incident and year of occurrence; processes involved and problems occurred in incidents involving failures during assistance; types of services and hospital units; patient profile; shift in which the incident occurred; degree of damage and deaths per incident. Results: Of the total records, 56.7% occurred in male people, 57.7% in the age group above 56 years of age, 54.3% in the day shift and 50.7% resulted in mild damage. The three main reasons for incidents and adverse effects were: Failures during healthcare (24.5%), pressure ulcers (21.6%) and patient falls (15.0%). In “failures during health care”, the procedures, treatment and / or intervention predominate (64.5%); in problems, incomplete or inadequate assistance (36.3%). The number of notifications four times higher in Paraná and twice in Santa Catarina suggests possible underreporting in Rio Grande do Sul. Conclusion: Failures predominated during health care in Paraná and Santa Catarina, and the patient's fall in Rio Grande do Sul