ABSTRACT
Objective:
To investigate the root causes of adverse events in a maternity hospital through risk management.
Method:
Action research with seven nursing professionals given their expressive capillarity in the service. The study was conducted between January 2020 and February 2021. The field of study was a public maternity hospital, in which a situational diagnosis of adverse events was carried out, and a questionnaire was applied to employees. In the thematic seminars, quality improvement tools were applied to identify the root causes of adverse events. Similar reports were grouped and analyzed.
Results:
With risk management, the root causes for adverse events related to patient identification, falls and prescription, use and administration of medications were identified.
Final considerations:
Weaknesses were observed in many fields that support adverse events. The institution must adopt consistent investments and collective attention. The study is still ongoing.
Keywords:
Health services; Patient safety; Risk management; Safety management; Nursing