Adverse events |
Minimal harm |
Drug allergy |
Allergenic predisposition. Failure to take complete patient history (communication failure with patient) |
Adverse events |
Minimal harm |
Decompensated diabetes |
Lack of medicine in pharmacy (administrative failures) |
Adverse events |
Minimal harm |
Decompensated schizophrenia |
Lack of medication and appropriate prescription form (administrative failures) |
Adverse events |
Minimal harm |
Pregnant woman with clinical complication |
Delay in delivering lab test. Laboratory far from patient’s neighborhood (administrative failures) |
Adverse events |
Minimal harm |
Severe malnutrition |
Elderly patient unable to explain problem to physician. Lives alone, little schooling, no family support. Professional with little time for the consultation (communication failure with patient) |
Adverse events |
Minimal harm |
Complications of hypertension, required hospitalization |
Did not understand correct use of medication. Took wrong dose, can’t read (communication failure with patient) |
Adverse events |
Minimal harm |
Medication did not produced desired effect in treatment of hypertension |
Lack of proper clinical follow-up of patient. Failure in staff training (patient care failures) |
Adverse events |
Minimal harm |
Elderly patient with hypotension and dehydration |
Drug-drug interaction /wrong dosage of medication (patient care failures) |
Adverse events |
Minimal harm |
Hyperglycemia |
Lack of medication (administrative failures) |
Adverse events |
Minimal harm |
Hospitalized for hypoglycemia |
Patient fails to take medication or eat when alone. Failure in family and caregiver support (failures in staff communication) |
Adverse events |
Minimal harm |
Intense headache |
The only specialist in the municipality failed to make the patient’s diagnosis or conduct an adequate physical examination, and ignored the referral from the FHS. Full agenda, overconfident; fatigue (patient care failures) |
Adverse events |
Minimal harm |
Patient with heart disease stopped taking medication |
Lack of funds to purchase medication (administrative failures) |
Adverse events |
Minimal harm |
Patient with intense headache, without diagnosis |
No access to neurologist and complex tests. Patient with serious social problem and stress requires support from health care unit and access to specialties (communication failure in the health care network) |
Adverse events |
Minimal harm |
Complication in clinical condition |
Patient refused to attend nursing consultation out of distrust for nursing care (communication failure with patient) |
Adverse events |
Minimal harm |
Fever, local pain, and edema |
Received wrong dose of vaccine due to error by nurse technician (patient care failures) |
Adverse events |
Minimal harm |
Complication of a respiratory allergy |
Patient failed to take medication. Shortage of medication in the pharmacy (administrative failures) |
Adverse events |
Minimal harm |
Complication of a respiratory allergy |
Patient failed to take medication. Shortage of medication in the pharmacy (administrative failures) |
Adverse events |
Minimal harm |
Gynecological complications |
Failure in diagnosis by the only specialist in the municipality, who failed to conduct a physical examination and ignored the examination by the FHS. Full agenda, overconfident, fatigue (patient care failures) |
Adverse events |
Minimal harm |
Decompensated hypertension + obesity |
Failure in access to specialist. Communication failure within the multidisciplinary team (communication failure in the health care network) |
Adverse events |
Moderate harm |
Complication of hypertension. In treatment for lupus |
Patient stopped taking medication due to financial difficulties. Failure in access to medication in the municipal pharmacy (administrative failures) |
Adverse events |
Moderate harm |
Nervous breakdown |
Abandoned treatment. Communication failure between health team members in the FHS, mental health, and the hospital (communication failure with patient) |
Adverse events |
Moderate harm |
Reduced mobility due to knee arthrosis |
Physical therapist responsible for home care refused treatment (patient care failures) |
Adverse events |
Moderate harm |
Complications in transfusion therapy |
Blood bag switched (patient care failures) |
Adverse events |
Moderate harm |
Patient hospitalized because of switched medications |
Patient took medication incorrectly and in the wrong amount. Failure in family support and communication by health care professional (communication failure with patient) |
Adverse events |
Moderate harm |
Hypoglycemia |
Excessive dose of medication was prescribed and patient was hospitalized (patient care failures) |
Adverse events |
Moderate harm |
Incorrect diagnosis of lupus |
Lab tests analyzed incorrectly. Laboratory error leading to test reorder (patient care failures) |
Adverse events |
Moderate harm |
Diarrhea |
Medication expired. Pharmacy failed to observe expiration date (patient care failures) |
Adverse events |
Moderate harm |
Diarrhea and fever |
Nurse technician failed to notice child’s last vaccination date and vaccinated on the wrong date. Failure in staff training and commitment (patient care failures) |
Adverse events |
Moderate harm |
Facial paralysis due to allergy to dipyrone. Hospitalized. |
Physician failed to take patient history and prescribed contraindicated medication (communication failure with patient) |
Adverse events |
Moderate harm |
Tachycardia |
Patient took medication that had expired. Lack of pharmacist in FHS units (administrative failures) |
Adverse events |
Moderate harm |
Patient in crisis failed to receive care |
Psychiatrist on vacation and no one saw the patient. Professional neglect (patient care failures) |
Adverse events |
Moderate harm |
Abscess in leg |
Incorrect technique in application of vaccine. Lack of experience and deficient professional training (patient care failures) |
Adverse events |
Moderate harm |
Decompensated hypertension and hyperglycemia |
Shortage of medication in pharmacy. Patient could not take medication (administrative failures) |
Adverse events |
Moderate harm |
Altered blood glucose |
Patient took wrong medication. Rushed appointments, without proper patient history. Failure in home follow-up by community health workers (communication failure with patient) |
Adverse events |
Moderate harm |
Patient with seizure, unable to schedule appointment with neurologist |
No appointment with specialist, no test results. Failure in organization of health care network (communication failure in health care network) |
Adverse events |
Moderate harm |
Patient dehydrated, malnourished |
Unable to obtain hospital admission. Family uninformed and low schooling (communication failure in health care network) |
Adverse events |
Moderate harm |
Altered blood glucose |
Patient does not follow staff instructions. Failure in follow-up by FHS team (communication failure with patient) |
Adverse events |
Moderate harm |
Allergic reaction to medications |
Failure in interaction between nursing staff and patient (communication failure with patient) |
Adverse events |
Moderate harm |
Hypotension |
Excess medication due to incorrect clinical management, due to failure to listen to patient. Rushed appointments (communication failure with patient) |
Adverse events |
Moderate harm |
Worsening of clinical condition due to delay in cancer diagnosis |
Delay in test results and lack of specialist to examine patient (communication failure in health care network) |
Adverse events |
Moderate harm |
Elderly patient with hypertension, not taking medication |
Fails to pick up medication at pharmacy due to family breakdown. A family leaves elderly patient at home alone (failures in staff communication) |
Adverse events |
Moderate harm |
Local pain, edema, fever |
Unwanted effect from vaccine. Failure in patient orientation (patient care failures) |
Adverse events |
Moderate harm |
Chest pain |
Delay in care at emergency unit (UPA) (communication failure in health care network) |
Adverse events |
Moderate harm |
Tachycardia |
Switched medication. Failure in drug dispensing and problems with physician’s handwriting. Lack of electronic patient chart (failures in staff communication) |
Adverse events |
Moderate harm |
Dehydration in elderly patient |
Failure in home visit. Failure in nursing triage (patient care failures) |
Adverse events |
Moderate harm |
Worsening of chronic renal failure |
Three to four-month delay in scheduling appointment with the only medical specialist (communication failure in health care network). |
Adverse events |
Permanent harm |
Depression with suicidal tendency |
Patient refuses treatment. No support from a mental health team (communication failure with patient) |
Adverse events |
Permanent harm |
Amputation of lower limb |
Lack of personal care/hygiene. Not following diet or prescribed medication. Lack of family support (communication failure with patient) |
Adverse events |
Permanent harm |
Decompensated hypertension + obesity |
Difficult access to specialist. Failure in health team communication (failures in staff communication) |
Adverse events |
Permanent harm |
Decompensated diabetes resulted in foot lesion |
Lack of patient’s adherence to treatment. Lack of patient monitoring by FHS team (communication failure with patient) |
Adverse events |
Permanent harm |
Atrophy of lower limbs |
Incorrect diagnosis/lack of access to physical therapy (patient care failures) |
Adverse events |
Permanent harm |
Stroke |
Patient failed to follow physician’s orientation. Failure to inform patient and family about severity of case (communication failure with patient) |
Adverse events |
Permanent harm |
Decompensated chronic illness |
Lack of patient monitoring by FHS team (communication failure with patient) |
Adverse events |
Permanent harm |
Stroke. In treatment for hypertension |
Difficult access to specialist (cardiologist) (communication failure in health care network) |
Adverse events |
Permanent harm |
Complications of stroke |
Lack of physical therapy service and follow-up by FHS (administrative failures) |
Adverse events * |
Permanent harm * |
Brain lesion in infant with fetal distress |
Lack of adequate prenatal care and lack of location for adequate care for patient (patient care failures) |
Adverse events |
Permanent harm |
Amputation of lower limb |
Delay in scheduling tests. Failure to schedule tests and medical appointment (patient care failures) |
Adverse events |
Permanent harm |
Patient had leg amputated |
Specialist failed to detect arterial obstruction. Delay in scheduling high-complexity exam (patient care failures) |
Adverse events |
Permanent harm |
Liver disease |
Specialist failed to make diagnosis. Apathy on the part of specialist. Lack of specialized tests: liver biopsy (patient care failures) |
Adverse events |
Permanent harm |
Stroke |
Failed to undergo complex tests due to lack of documentation. Social service was slow to act. Failure in humanization program (patient care failures) |
Adverse events |
Permanent harm |
Rapid evolution of cancer before reaching specialist |
Delay in appointment with specialist. Delay in biopsy result (communication failure in health care network) |
Adverse events |
Permanent harm |
Complication of diabetic foot |
Error and delay in care. Lack of proper technique and adequate place for changing dressing (patient care failures) |
Adverse events |
Permanent harm |
Complication from drug-drug interaction |
Lack of ethics and technical knowledge. Irresponsibility (patient care failures) |
Adverse events |
Permanent harm |
Elderly patient with facial injury, redness, and edema |
Physical abuse by family member. Failure of the FHS team to engage with social service (failures in staff communication) |
Adverse events |
Permanent harm |
Liver disease in alcoholic patient |
Failure in follow-up by FHS team to reduce patient’s alcohol consumption (communication failure with patient) |
Adverse events |
Permanent harm |
Atrophy of lower limbs in alcoholic patient |
Failure in follow-up by FHS team to reduce patient’s prolonged alcohol consumption and patient’s failure to take medication (communication failure with patient) |
Adverse events |
Permanent harm |
Worsening of Alzheimer disease in elderly patient |
Patient fails to take medication correctly. Failure in follow-up by FHS team and family support (communication failure with patient) |
Adverse events |
Permanent harm |
Psychiatric disorder |
Lack of medication due to incapacity to dispense controlled medication (administrative failures) |
Adverse events |
Permanent harm |
Stroke. Severe hypertension. Alcoholism |
Patient’s aggressive behavior and irregular use of medication. Failure in family support (communication failure with patient) |
Adverse events |
Permanent harm |
Acute myocardial infraction. Hypertension, irregular use of medication |
Patient’s lack of awareness of health condition (communication failure with patient) |
Adverse events |
Permanent harm |
Worsening of clinical status. Alcoholic, refuses to take medication or receive visit from community health workers |
Alcoholism results in patient refusing treatment (communication failure with patient) |
Adverse events |
Permanent harm |
Anorexia, depression, dehydration |
Lack of access to psychiatrist and psychologist (communication failure in health care network) |
Adverse events |
Permanent harm |
Torn biceps tendons |
Diagnostic error by orthopedist, who failed to schedule surgery (patient care failures) |
Adverse events |
Permanent harm |
Amputated foot due to diabetes |
Incorrect dressing and treatment by nursing and physician staff (patient care failures) |
Adverse events |
Permanent harm |
Neuropsychiatric disorder due to alcohol dependence |
Lack of treatment for alcohol addiction (failures in staff communication) |
Adverse events |
Permanent harm |
Worsening of clinical condition |
Patient had to resubmit to preventive test due to failure to receive result. Organizational failure by laboratory and FHS (patient care failures) |
Adverse events |
Permanent harm |
Evolution of obesity to grade 3. Decompensated hypertension |
Difficulty in access to specialist and misinformation on proper nutrition. Lack of patient monitoring by FHS team (failures in staff communication) |
Adverse events |
Permanent harm |
Atrophy of lower limbs |
Lack of access to physical therapy (communication failure in health care network) |
Adverse events |
Death |
Cardiovascular complications |
Treatment delay at UPA (communication failure in health care network) |
Adverse events |
Death |
Complication of chest pain |
Hospital refused treatment. Communication failure between FHS and hospital (communication failure in health care network) |
Adverse events |
Death |
Decompensated diabetes |
Failure in patient follow-up by FHS (communication failure with patient) |
Adverse events |
Death |
Hyperglycemia |
Communication failure between FHS team and hospital (communication failure in health care network) |
Adverse events * |
Death * |
Premature delivery due to urinary infection and hypertension. Newborn infant died |
Pregnant woman was not referred to high-risk prenatal service, but seen by nursing staff. Failure in staff communication and noncompliance with protocol for high-risk pregnancy (failures in staff communication) |
Adverse events |
Death |
Hypertension, requiring pacemaker, poorly assessed by specialist and died |
Inadequate clinical assessment by cardiologist and inadequate tests (patient care failures) |
Adverse events |
Death |
Acute respiratory failure, COPD |
Patient refused treatment by FHS team, lives alone (communication failure with patient) |
Adverse events |
Death |
Respiratory complications in elderly patient |
Delay in treatment at UPA (communication failure in health care network) |
Adverse events |
Non-classifiable |
Depression |
Patient refuses treatment. No support from mental health team (communication failure with patient) |
Adverse events |
Non-classifiable |
Depression |
Patient refuses treatment. No support from mental health team (communication failure with patient) |
Adverse events |
Non-classifiable |
Evolution of obesity to grade 3. Decompensated hypertension |
Difficulty in access to specialist. Misinformation on healthy eating. Lack of patient monitoring by FHS team (communication failure in health care network) |
Adverse events |
Non-classifiable |
Uterine cervical cancer, despite annual Pap smear |
Laboratory not prepared to conduct cytopathology tests, failure in quality inspection of laboratories (administrative failures) |
Harmless incident |
Non-classifiable |
Pregnant woman with gestational diabetes, had premature delivery |
Difficulty in access to specialist (communication failure in health care network) |
Harmless incident |
Non-classifiable |
Patient had to redo lab tests |
Material collected incorrectly. Failure in training lab technician (patient care failures) |
Adverse events |
Non-classifiable |
Decompensated chronic illness |
Patient missed appointment. Failure in follow-up by nursing staff and community health workers (communication failure with patient) |
Adverse events |
Non- classifiable |
Respiratory failure in patient with HIV |
Hospital refused treatment. Communication failure between FHS and hospital (communication failure in health care network). |
Harmless incident |
Non-classifiable |
Patient with intense headache, unable to undergo cranial computed tomography |
Reception forgot to schedule, and when they did schedule the test, there was no vehicle to transport the patient (patient care failures) |
Adverse events |
Non-classifiable |
Psychiatric crisis |
Skipped controlled prescription medication. Failure in access to specialist and in referral services (communication failure in health care network) |
Harmless incident |
Non-classifiable |
Patient failed to take prescribed medication |
Patient can’t read and is unable to distinguish which medication to take. Failure in support and communication from community health workers (communication failure with patient) |
Harmless incident |
Non-classifiable |
Patient’s chart disappeared. Difficulty in conducting diagnosis |
Patient chart filed in wrong place. Insufficient number of receptionists and insufficient training (patient care failures) |
Harmless incident |
Non-classifiable |
Patient chart switched |
Wrong medication prescribed for patient. Lack of electronic patient chart and trained reception staff (patient care failures) |
Harmless incident |
Non-classifiable |
Patient chart disappeared. Difficulty prescribing medication |
Patient chart filed incorrectly. Failure in training reception staff (patient care failures) |
Adverse events |
Non-classifiable |
Patient undiagnosed, even when seen by specialists |
Lack of professional interest. Lack of communication between professionals. Failure in completing referral and counter-referral form (patient care failures) |
Incident did not reach patient |
Non-classifiable |
Wrong patient chart |
Failure to check patient’s name on patient chart. Failure at reception (patient care failures) |
Incident did not reach patient |
Non- classifiable |
Postpartum patient missed infant care appointment |
Missed scheduled appointment. Mother’s carelessness. Heavy workload for community health workers (communication failure with patient) |
Harmless incident |
Non-classifiable |
Patient was not referred to specialist and went untreated |
Lack of professional accountability for not having referred patient to specialist (patient care failures) |
Adverse events |
Non-classifiable |
Edema and pain in right leg in child |
Error in vaccination site. Lack of experience and poor professional training (patient care failures) |
Incident did not reach patient |
Non-classifiable |
Child’s name was not on appointment list. Mother missed a day of work |
Work overload. Absence of reception staff. Carelessness and lack of training (patient care failures) |
Incident did not reach patient |
Non-classifiable |
Patient’s name was not on appointment list. Missed a day of work |
Long wait for appointment, and patient was not able to be seen (administrative failures) |
Harmless incident |
Non-classifiable |
Mistaken diagnosis of diabetes |
Mistake on blood test. No clinical examination was performed. Limited involvement by health care professional. Low-quality laboratories (patient care failures) |
Incident without lesion |
Non-classifiable |
Patient had to return to health care unit because the blood sample was insufficient |
Lab technician did not draw sufficient blood. Deficient technical training (patient care failures) |
Incident without lesion |
Non-classifiable |
Patient had to return to health care unit because the blood sample was insufficient |
Lab technician did not draw sufficient blood. Deficient technical training (patient care failures) |
Harmless incident |
Non- classifiable |
Pregnant returned from hospital without adequate treatment, entered labor in the FHS unit |
Lack of hospital beds. Lack of professional preparedness. Humanization (communication failure in health care network) |
Incident did not reach patient |
Non-classifiable |
Patient charts switched due to identical names |
Inadequate completion of registration forms. Failure in training for reception staff. Lack of electronic patient chart (patient care failures) |
Incident without lesion |
Non-classifiable |
Patient with abdominal pain and bleeding, unable to schedule ultrasound |
Failure in referral and counter-referral (communication failure in health care network) |
Incident without lesion |
Non-classifiable |
Patient with hypertension, unable to schedule with cardiologist |
Patient in financial straits. Failure in scheduling appointment in the SUS (communication failure in health care network) |
Adverse events |
Non-classifiable |
Complication in patient with neurological disease |
Medication administered incorrectly (patient care failures) |
Adverse events |
Non-classifiable |
Complicated tonsillitis |
Only used home remedies such as herbal teas. Failure to access pediatrics or FHS (failures in staff communication) |
Incident without lesion |
Non-classifiable |
Patient decided not to take medication |
Lack of information and low schooling. Failure in family support (communication failure with patient) |
Incident without lesion |
Non-classifiable |
Patient missed medication |
Lack of medication in pharmacy (administrative failures) |
Incident did not reach patient |
Non-classifiable |
Patient arrived at scheduled time, but physician had already left |
It was raining and patient was left with no transportation to return home. Failure by physician to comply with 40-hour workweek (patient care failures) |
Incident did not reach patient |
Non-classifiable |
Pregnant woman arrived late, physician had already left |
Patient lives far from health care unit (administrative failures) |
Incident did not reach patient |
Non-classifiable |
Switched medication on prescription |
Carelessness in dispensing. Physician’s handwriting illegible. Lack of electronic patient chart (failures in staff communication) |
Incident did not reach patient |
Non-classifiable |
Tests switched |
Carelessness in delivering medication. Physician’s handwriting illegible (failures in staff communication) |
Incident did not reach patient |
Non-classifiable |
Patient was refused scheduling of tests, on grounds that he was not carrying any identification |
Excess bureaucracy. Sluggish social service. Failure by patient to demand accountability (patient care failures) |
Incident did not reach patient |
Non-classifiable |
Patient unable to schedule tests |
Patient unable to enter scheduling line. Failure in referral and couter-referral (communication failure in health care network) |
Incident did not reach patient |
Non-classifiable |
Elderly patient refused to take influenza vaccine |
Misinformation. Failure in specific orientation / communication for the elderly (communication failure with patient) |
Incident without lesion |
Non-classifiable |
Patient received another patient’s test result. |
Lack of electronic patient chart (patient care failures) |
Incident without lesion |
Non-classifiable |
Community health workers failed to inform patient properly about family planning |
Community health workers did not understand nursing staff’s request and transmitted erroneous information. Failure in training (failures in staff communication) |
Incident did not reach patient |
Non-classifiable |
Patient not treated at the health care unit |
Power outage at the FHS unit, due to lack of a generator (administrative failures) |