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.

METHOD

A descriptive and retrospective study of incidents reported between January 2011 and September 2014.

RESULTS

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.

CONCLUSION

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.

Descriptors
Patient Safety; Risk Management; Quality of Health Care; Health Services Evaluation

Incidents	N	%
Category
Reportable occurrence	22	10.5
Near Miss	16	7.7
Incident without injury	4	1.9
Incident with injury (adverse event)	167	79.9
Degree of damage
None	42	20.1
Slight	131	62.7
Moderate	30	14.3
Severe	6	2.9
Death	0	0
Total	209	100

Variable	N	%
Professional category
Nurse	55	26.3
Doctor	12	5.7
Professional ombudsman	5	2.4
Nursing technician	5	2.4
Physiotherapist	3	1.4
Pharmacist	2	1
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	127	60.8
Place/site of occurrence
Admission	23	11
Psychiatry	14	6.7
Intensive care unit	14	6.7
Emergency Room stalls	5	2.4
Pharmacy	4	1.9
Neurocardiovascular center	4	1.9
Outpatient clinic	3	1.4
Core of the Surgical Center	3	1.4
Emergency	3	1.4
Hemodynamics	3	1.4
Neurosurgery	2	1
Others	7	3.5
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	124	59.3
Total	209	100

Profile of patients	N	%
Gender
Female	82	47.9
Male	67	39.2
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	22	12.9
Age group
Less than 1 year of age	4	2.4
1 to 15	9	5.2
16 to 25	21	12.3
26 to 35	14	8.2
36 a 45	23	13.4
46 to 60	26	15.2
Over 60	40	23.4
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	34	19.9
Length of hospital stay until the time of the incident
0 to 5 days	10	5.9
6 to 15 days	8	4.6
16 to 30 days	11	6.4
31 to 40 days	11	6.4
41 to 50 days	10	5.9
51 to 60 days	7	4.1
More than 60 days	10	5.9
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	104	60.8
Origin
Federal District	74	43.3
Other federal units	23	13.4
Not informed^* * Data could not be obtained due to incomplete or incorrect completion of notification.	74	43.3
Total	171	100

Types of incidents	Reportable occurrence		Near miss		Incident without injury		Incident with injury (adverse event )		Total
Types of incidents	n	%	n	%	n	%	n	%	n	%
Clinical management	0	-	1	6.2	0	-	1	0.6	2	1.0
Clinical process/procedure	0	-	0	-	1	25	10	5.9	11	5.3
Documentation	0	-	0	-	0	-	0	-	0	-
Infections associated to health care	0	-	0	-	0	-	1	0.6	1	0.5
Intravenous medication/fluid	0	-	14	87.6	2	50	5	3.0	21	10.0
Blood/hemoderivative	0	-	0	-	0	-	105	62.9	105	50.2
Nutrition	0	-	0	-	0	-	0	-	0	-
Oxygen/gas/vapor	0	-	0	-	0	-	0	-	0	-
Medical devices/medical equipment	19	86.4	1	6.2	0	-	14	8.4	34	16.3
Behavior	0	-	0	-	1	25	0	-	1	0.5
Patient accident	0	-	0	-	0	-	31	18.6	31	14.8
Infrastructure/buildings/facilities	0	-	0	-	0	-	0	-	0	-
Resources/organizational management	0	-	0	-	0	-	0	-	0	-
Total	22	100	16	100	4	100	167	100	209	100

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Leila Bernarda Donato Göttems. Edifício Fepecs - SMHN, Quadra 03, CEP: 70710-907 - Brasília, DF, Brazil. leila.gottems@gmail.com