A study of cases reported as incidents in a public hospital from 2011 to 2014

Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. A descriptive and retrospective study of incidents reported between January 2011 and September 2014. 209 reported incidents were categorized as repor...

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Bibliographic Details
Published in:	Revista da Escola de Enfermagem da U S P Vol. 50; no. 5; pp. 861 - 867
Main Authors:	Göttems, Leila Bernarda Donato, Santos, Maria do Livramento Gomes Dos, Carvalho, Paloma Aparecida, Amorim, Fábio Ferreira
Format:	Journal Article
Language:	English
Published:	Brazil Universidade de São Paulo, Escola de Enfermagem 01-09-2016 SciELO
Subjects:	Adolescent Adult Avaliação de Serviços de Saúde Brazil Child Child, Preschool Female Gestão de Riscos Hospitals, Public Humans Infant Male Middle Aged NURSING Qualidade da Assistência à Saúde Retrospective Studies Risk Management - statistics & numerical data Segurança do Paciente Time Factors Young Adult Gestão de Riscos Health Services Evaluation Calidad de la Atención de Salud Patient Safety Gestión de Riesgos Seguridad del Paciente Segurança do Paciente Evaluación de Servicios de Salud Avaliação de Serviços de Saúde Risk Management Quality of Health Care Qualidade da Assistência à Saúde
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Summary:	Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. A descriptive and retrospective study of incidents reported between January 2011 and September 2014. 209 reported incidents were categorized as reportable occurrences (n = 22, 10.5%), near misses (n = 16, 7.7%); incident without injury (n = 4, 1.9%) and incident with injury (adverse events) (n = 167, 79.9%). The average age of patients was 44 years and the hospitalization time until the moment of the incident was on average 38.5 days. Nurses were the healthcare professionals who most reported the incidents (n = 55, 67%). No outcomes resulted in death. Incidents related to blood/hemoderivatives, medical devices/equipment, patient injuries and intravenous medication/fluids were the most frequent. Standardizing the reporting processes and enhancing participation by professionals in managing incidents is recommended. Analisar os incidentes notificados em um hospital público do Distrito Federal, segundo as características e os desfechos quando envolveram pacientes. Estudo descritivo e retrospectivo dos incidentes notificados entre janeiro de 2011 e setembro de 2014. Notificados 209 incidentes categorizados em ocorrência comunicável (n = 22, 10,5%), quase evento (n = 16, 7,7%), incidente sem dano (n = 4, 1,9%) e incidente com dano (eventos adversos) (n = 167, 79,9%). A idade média dos pacientes foi de 44 anos e o tempo da internação até o momento do incidente teve média de 38,5 dias. Os enfermeiros foram os que mais notificaram (n = 55, 67%). Nenhum desfecho resultou em morte. Os incidentes relacionados a sangue/hemoderivados, dispositivos/equipamento médico, acidentes do doente e medicação/fluidos endovenosos foram os mais frequentes. Recomenda-se padronizar os processos de notificação e potencializar a participação dos profissionais no manejo dos incidentes.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0080-6234 1980-220X 0080-6234
DOI:	10.1590/S0080-623420160000600021