Characteristics of adverse events in primary health care in Brazil

Marchon, Simone Grativol; Mendes Junior, Walter Vieira; Pavão, Ana Luiza Braz

doi:10.1590/0102-311X00194214

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Cadernos de Saúde Pública

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ARTICLE • Cad. Saúde Pública 31 (11) • Nov 2015 • https://doi.org/10.1590/0102-311X00194214 copy

Characteristics of adverse events in primary health care in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aimed to evaluate the occurrence of incidents in primary health care in Brazil. Fifteen health professionals working in Family Health Strategy units agreed to anonymously and confidentially record incidents over the course of five months, using the questionnaire Primary Care International Study of Medical Errors (PCISME) questionnaire adapted to the Brazilian context. The overall rate of incidents was 1.11%. The rate of incidents that did not reach patients was 0.11%. The rate of incidents reaching patients but without causing harm was 0.09%. The rate of incidents reaching patients and causing adverse events was 0.9%. Eight types of most frequent errors and administrative failures were identified. Communication failures were the most common contributing factor to incidents in primary health care (53%). The findings show that incidents occur in primary health care (as elsewhere in the health system), but research in this area is still incipient.

Patient Safety; Health Evaluation; Primary Health Care

Characteristics/Categories	Incidents that did not reach the patient	Reached the patient but did not cause harm	Adverse events	Total
Characteristics/Categories	n (%)	n (%)	n (%)	n (%)
Sex
Male	10 (17.5)	11 (19.3)	36 (63.2)	57 (45.6)
Female	11 (16.2)	26 (38.2)	31 (45.6)	68 (54.4)
Age bracket (years)
≤ 9	1 (10.0)	4 (40.0)	5 (50.0)	10 (8.0)
10-19	1 (12.5)	2 (25.0)	5 (62.5)	8 (6.4)
20-59	15 (23.4)	21 (32.8)	28 (43.8)	64 (51.2)
≥ 60	4 (9.3)	10 (23.3)	29 (67.4)	43 (34.4)
Presence of chronic diseases
Yes	13 (15.5)	21 (25.0)	50 (59.5)	84 (67.2)
No	8 (19.5)	16 (39.0)	17 (41.5)	41 (32.8)
Social vulnerability
Yes	5 (8.6)	17 (29.3)	36 (62.1)	58 (46.4)
No	16 (23.9)	20 (29.9)	31 (46.3)	67 (53.6)
Total	21 (16.8)	37 (29.6)	67 (53.6)	125 (100.0)

Type of incident	Severity	Consequence	Contributing factors
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)

Errors	Brazilian study	Portuguese study	Australian study
Errors	n (%)	n (%)	n (%)
Administrative errors	32 (26)	19 (48)	26 (20)
Errors in the investigation of tests	7 (5)	10 (25)	17 (13)
Treatment errors	24 (19)	2 (5)	38 (29)
Communication errors	27 (22)	6 (15)	20 (15)
Payment errors	0 (0)	0 (0)	1 (1)
Errors in human resources management	3 (2)	1 (2)	2 (1)
Errors in the performance of clinical tasks	17 (14)	0 (0)	7 (5)
Diagnostic errors	15 (12)	2 (5)	21 (16)
Total	125 (100)	40 (100)	132 (100)

Place	Brazilian study	Portuguese study	Australian study
Place	%	%	%
Physician’s office	25	62	64
Hospital	15	7	12
Patient’s home	11	0	8
Pharmacy	10	2	4
Reception	9	10	0
Laboratory	8	5	6
Nursing station	7	2	0
Outpatient departments (specialties)	4	0	0
Immunization room	3	0	0
UPA	3	0	0
Telephone contact	2	5	4
Imaging laboratory	1	7	2
Transportation	1	0	0
Transfusion therapy service	1	0	0
Total	100	100	100

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
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[1] Correspondence
S. G. Marchon. Rua Senador Pompeu 208, Araruama, RJ. 28970-000, Brasil.. simonemarchon@gmail.com