Análise dos incidentes relacionados à segurança do paciente notificados em um hospital público da cidade de Fortaleza-Ce

Abstract

Health services have been dedicated to providing improvements in the quality of patient care, especially those admitted to hospital units. However, health teams are constantly susceptible to errors during their activities. In this way, errors during health care can result in an incident resulting from the inadequate execution of a planned action. The objective was to analyze incidents related to patient safety reported by health professionals in a public hospital, based on the Taxonomy of Patient Safety. Descriptive, documentary research, with a quantitative approach and with a retrospective design, developed from March to June 2023, based on the internal incident notification system of the Patient Safety Center. 911 notifications referring to the period from January to December 2022 were analyzed. After applying the inclusion and exclusion criteria, 596 notifications were selected for sample composition. The adopted data collection instrument was a Checklist, prepared by the researcher, based on the updated literature and on the taxonomy of patient safety. The collected data were organized in Microsoft Excel® spreadsheets. These were analyzed based on descriptive statistics, and presented in absolute and relative frequencies, in the form of tables and graphs. The present research is part of a multiphase mixed methods study that was approved by the ethics committee. As a result, incidents that occurred with male patients and aged over 51 years predominated. Most incidents occurred in treatment-related procedures (97.7%) and during care delivery (85.10%). The sector with the highest number of incidents was the emergency (35.80%), followed by the medical clinic (34.2%). The day of the week with the highest number of incidents was Friday (18.1%). The day shift in which the most incidents occurred was the night shift (37.4%). The professionals who reported the most were nurses (94.50%). The most reported type of incident was AE (69.5%). Regarding damage, mild damage was prevalent with 47.4%. With regard to the characteristics of the incidents, it was found that failure during assistance (61%) and pressure injury (55.8%) were the most reported. With regard to contributing factors, the main ones were related to performance (56.6%), the patient (50.8%) and the environment (48.6%). As for the identification of incidents, 95.8% were detected through proactive risk assessment and that 99.7% of these were identified by health professionals. It was found that data related to the organizational consequences of the incidents were not reported in the notifications (94.5%). Likewise, mitigating factors for damage (97.3%) and improvement actions (90.8%) were not mentioned in the notifications. The study made it possible to identify incidents related to patient safety, making it possible to identify weaknesses so that managers can institute daily practices of permanent education in order to guarantee the development of quality and safe care.