Objective: to identify the incidents and adverse events notified in a large size hospital. Methods: a retrospective study was carried out based on data extracted from handwritten notifications sheets, made available by the Patient Safety Nucleus of a large size hospital. The following variables were analyzed: type of incident, according to international safety goals; severity of the incidents with damage; and measures proposed to minimize the effects of the notified incident. Results: among the 1167 notifications, 653 (66.8%) of the incidents were related to pharmacovigilance, 563 (48.6%) presented as potential harm, 355 (28.7%) caused harm to the patient and of these, 228 (68.0%) were of mild intensity. Proposed actions were described in 705 (60.4%) of the notifications. Conclusion: the notifications allowed identifying a high number of incidents with potential to cause harm, denoting failures that could be minimized with the implementation of institutional protocols and professional training.
Identificar os incidentes relacionados a medicamentos notificados ao núcleo de segurança do paciente de um hospital de grande porte. Métodos: Estudo transversal, retrospectivo realizado a partir de dados extraídos das fichas de notificações de incidentes, no período de janeiro de 2017 a dezembro de 2018. Análise dos dados foi realizada por meio de estatística descritiva. Resultados: Foram processadas 627 notificações de erros farmacológicos, 33,9% erros de prescrições, 36,2% erro de dispensação, 18,5% erro de administração, 2,5% queixa técnica e 8,7% reação adversa ao medicamento, sendo o quimioterápico o medicamento com reações mais notificadas, destas 76,3% de causalidade provável, 16,3% definida e 7,2% possível. O erro sem dano prevaleceu em 325 dos relatos. As medidas adotadas estavam em 63,4% dos casos. Conclusão: As notificações são eficazes para realizar ações específicas de melhoria que podem influenciar na prevenção, aumentando a segurança do paciente.
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