Registry of adverse events related to health care that results in deaths in Brazil, 2014-2016

Abstract

Objective:

to describe the adverse events related to health care resulting in death.

Methods:

a descriptive study of reports recorded in the Brazilian Health Surveillance Notification System (Notivisa) in Brazil from Jun 2014 to Jun 2016; notifications recorded as 'other' in the 'incident type' were recoded.

Results:

417 cases were recorded, mostly in adults and the elderly (85%), with no sex differences; the states of São Paulo (N=92), Paraná (N=75) and Minas Gerais (N=66) were the main reporter; hospitals contributed to 97% of the records, principally in the intensive care and hospitalization sectors; the investigation by the notifying unit occurred in 5% of cases; in the recode of the type of incident, 52 records were recovered; the most common type of incident was 'failures during health care' (50%).

Conclusion:

notifications resulting in death occurred mainly in hospitals; were identified failure to register and need to investigate the large proportion of deaths.

Keywords:
Patient Safety; Information Systems; Death; Health Services; Epidemiology, Descriptive