Patient safety incidents and adverse events reported by Brazilian citizens: a descriptive study, 2014-2018

Villar, Vanessa Cristina Felippe Lopes; Martins, Mônica; Rabello, Elaine Teixeira

Acessibilidade / Reportar erro

Brasil

Epidemiologia e Serviços de Saúde

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Brasil

Español English

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Sumário

ORIGINAL ARTICLE • Epidemiol. Serv. Saúde 30 (4) • 2021 • https://doi.org/10.1590/S1679-49742021000400007 copy

Patient safety incidents and adverse events reported by Brazilian citizens: a descriptive study, 2014-2018

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To describe incidents related to healthcare services reported by Brazilian citizens on the Health Surveillance Notification System.

Methods:

This was a descriptive study, using the database from the Health Surveillance Notification System (Notivisa) of the Brazilian Health Regulatory Agency (Anvisa), 'citizen' module, between 2014 and 2018.

Results:

935 incidents were reported, most of them occurred among females (60.9%), the elderly (20.1%) and those of white race/skin color (51.0%). The majority of the reported incidents were related to the use of medications (50.8%), falls (7.5%) and healthcare-associated infections (HAIs) (7.2%), which occurred during provision of healthcare, treatment or surgery (37.3%), in daytime (58.3%) and in hospital setting (37.4%).

Conclusion:

It could be seen a low adherence to the notification system among the citizens. There was a higher frequency of incidents related to medications, falls and HAIs. This shows that citizens have the capability to recognize and report these incidents as patient safety issues.

Keywords:
Patient Safety; Information Systems; Patient Participation; Quality of Health Care; Descriptive Epidemiology.

Types of incidents	n	%
Medications uses	475	50.8
Patient falls	70	7.5
Healthcare-associated infections	67	7.2
Administrative activities	56	6.0
Health product	40	4.3
Pressure ulcer	36	3.9
Use of blood and derivatives	24	2.6
Patient identification	18	1.9
Surgery	17	1.8
Patient protection and care failures	7	0.8
Clinical or pathology laboratories	6	0.6
Patient accidents	5	0.5
Radiological service	4	0.4
Blood donation or blood components	2	0.2
Transplantation, grafting or fertilization	2	0.2
Dietary management	1	0.1
Other	105	11.2
Total	935	100.0

Types of incidents that were reported and reclassified	n	Examples of reported incident
Clinical process/clinical procedure	29	Poorly fixed central venous access, leading to procedure failure. Phlebitis due to venous puncture
Behavior	9	Aggressive patient companion Violence toward staff
Human resource and organizational management	8	Lack of pediatric care. Employees not qualified for the job or workplace deviation
Structure	6	Improperly disposed of medical waste. Female infirmary without bathroom for patient’s selfcare, due to the need for a bathroom renovation, by order of the manager. Lack of supply (bed sheet, soap, alcohol; employees).
Neurological disorders	5	Patient presenting with agitation and confusion, trying to leave the healthcare sector. Convulsion
Vaccines	5	Vaccine administration error. Vaccine side effects, fever over 40º C.
Allergy	4	Allergy due to ultasound gel
Circulatory System diseases	2	Cardiogenic shock
Gastrointestinal disorders	1	Bloody diarrhea
Protocol adherence failure	1	No hand hygiene
Total	70

Variable	N	%
Individual responsible for the notification
Other	462	49.4
Affected person	239	25.6
Family member	146	15.6
Friend	48	5.1
Caregiver	40	4.3
Sex
Female	569	60.9
Male	366	39.1
Age group (years)
≤1	58	6.2
2-4	17	1.8
5-11	14	1.5
12-17	20	2.1
18-25	116	12.4
26-35	167	17.9
36-45	115	12.3
46-55	94	10.1
56-65	146	15.6
≥66	188	20.1
Race/skin color
White	477	51.0
Brown	245	26.2
Black	46	4.9
Asian	22	2.4
Indigenous	4	0.4
Had no information	141	15.1
Total	935	100,0

Variables	n	%
Care steps or moment
During the provision of care, treatment or surgery	349	37.3
The patient was not hospitalized	346	37.0
During diagnosis	107	11.5
During the admission or access to health service	88	9.4
During follow-up after discharge	22	2.4
At the time of discharge	14	1.5
During transfer to another institution or service	5	0.5
During or after blood donation	4	0.4
Incident location
Hospital setting	350	37.4
Outside the health service	279	29.8
Outpatient clinic	85	9.1
Pharmacy or drugstore	61	6.5
Primary Health Center	49	5.3
Emergency care center	39	4.2
Nuclear medicine	35	3.7
Radiological service	12	1.3
Hemodialysis service	11	1.2
Clinical analysis laboratory and pathological anatomy	10	1.1
Mental and psychiatric health service or institution	4	0.4
Period of the day
In daytime	545	58.3
During the night or at dawn	166	17.7
Had no information	224	24.0
Incident severity
Mild	308	32.9
Moderate	247	26.4
Severe	225	24.1
None	133	14.2
Death	22	2.4
Total	935	100.0

Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil SRTVN Quadra 701, Via W5 Norte, Lote D, Edifício P0700, CEP: 70719-040, +55 61 3315-3464, Fax: +55 61 3315-3464 - Brasília - DF - Brazil
E-mail: ress.svs@gmail.com

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[1] Correspondence: Vanessa Cristina Felippe Lopes Villar - Instituto Nacional de Infectologia Evandro Chagas, Avenida Brasil, No. 4365, Manguinhos, Rio de Janeiro, RJ, Brasil. CEP: 21040-360 E-mail: vanessalopesvillar@gmail.com