Analysis of incidents notified in a general hospital

Abstract

Objective: To evaluate the incidents spontaneously notifi ed in a general hospital in Minas Gerais. Method: Retrospective, descriptive, quantitative study performed at a general hospital in Montes Claros -Minas Gerais State. The sample comprised 1,316 incidents reported from 2011 to 2014. The data were submitted to descriptive statistical analysis using Statistical Package for the Social Sciences version 18.0. Results: The prevalence of incidents was 33.8 per 1,000 hospitalizations, with an increase during the investigation period and higher frequency in hospitalization units, emergency room and surgical center. These occurred mostly with adult clients and relative to the medication supply chain. The main causes were noncompliance with routines/protocols, necessitating changes in routines and training. Conclusion: There was a considerable prevalence of incidents and increase in notifi cations during the period investigated, which requires the attention of managers and hospital staff. Nevertheless, we observed development of the patient safety culture. Descriptors: Patient Safety; Safety Management; Quality of Health Care; Quality Assurance in Health Care; Nursing. RESUMO Objetivo: avaliar os incidentes notifi cados espontaneamente em um hospital-geral de Minas Gerais. Método: estudo retrospectivo, descritivo, quantitativo, realizado em hospital-geral de Montes Claros -MG. A amostra foi composta de 1316 incidentes notifi cados entre 2011 a 2014. Os dados foram submetidos à estatística descritiva no software Statistical Package for the Social Sciences versão 18.0. Resultados: A prevalência de incidentes foi de 33,8 por 1.000 internações, tendo sido evidenciados aumento ao longo do período investigado e maior frequência nas unidades de internação, no setor de emergência e centro cirúrgico. Houve maior ocorrência em clientes adultos e relativos à cadeia medicamentosa. As principais causas foram o descumprimento da rotina/protocolo, sendo necessárias mudanças na rotina e no treinamento. Conclusão: Houve considerável prevalência de incidentes e aumento de notifi cações no período investigado, o que requer atenção dos gestores e colaboradores, apesar de observado o desenvolvimento da cultura de segurança do paciente. Descritores: Segurança do Paciente; Gestão da Segurança; Qualidade da Assistência à Saúde; Garantia da Qualidade dos Cuidados de Saúde; Enfermagem. RESUMEN Objetivo: evaluar los incidentes notifi cados espontáneamente en un hospital general de Minas Gerais. Método: estudio retrospectivo, descriptivo, cuantitativo, realizado en hospital general de Montes Claros -MG. La amuestra fue compuesta de 1316 incidentes notifi cados entre 2011 y 2014. Los datos fueron sometidos a la estadística descriptiva en softwareStatisticalPackage for the Social Sciences versión 18.0. Resultados: La prevalencia de incidentes fue de 33,8 por 1.000 internaciones, habiendo sido evidenciados aumento a lo largo del período investigado y mayor frecuencia en las unidades de internación, en el sector de urgencia y centro quirúr...

Segurança do paciente na perspectiva de gestantes e puérperas

“…15 In this environment, cases of near miss were found, mainly due to the supply of medicines that the patients did not use, being intercepted in the last barrier. The findings are compared to the surveys performed in other establishments [7][8] , which identified more errors in the obstetric area and found a higher index related to medications and intravenous fluids, 16 with prevalence in hospitalization units. [7][8]16 It is pointed out that, in relation to the previous use of medicines, this research stood out little compared to the one that found 34% of use for pre-existing diseases, 17 and a Belgian study, 18 that registered 1.4% of drug use by pregnant women.…”

“…13 The satisfaction of the patients with the offered care (95%) was highlighted, according to another study carried out at the same institution, but with a different clientele, which identified precariousness in basic care, extending to the maternal area. 14 It is suggested, however, that strategies that include cultural, structural and organizational influences should be improved in order to promote changes in the multiprofessional team, reflecting their routines, complying with the protocols, conducting trainings, 7,10 favoring patient orientations, sharing decisions and establishing ethical relationships. 5,15 The PSNP proposals include the commitment of professionals and daily reflection on attitudes and behaviors, inserting a model of safe, patient-centered care and with the correct identification of those involved in the environment.…”

“…The incidence of 10.21 maternal near miss occurrences per 1,000 live births, associated with previous cesarean delivery, to gestation risk, the fact that there was no prenatal care, and aged 35 years or more was identified. 6 A recent survey found 33.8 incidents per thousand hospitalizations, 37 of which involved maternity, 7 and in another, 1.1% of all hospitalizations represented the maternal area, with 12 cases. 8 In view of these findings, it is stated that numerous initiatives have arisen to organize, standardize, implement and qualify this assistance.…”

“…It is understood that such changes must contemplate the professionals, the patients and the structural and organizational adaptation of the maternities, mediated by a vigilant management and committed to the safe and quality care. 5,7 It is observed the lack of studies involving the patients' understanding of PS, but, in a research, the importance of this involvement was verified, presenting, as obstacles, the lack of knowledge about the concepts, the concern with the conflict in the professional / patient relationship, among others. 11…”

Análise De Circunstâncias Notificáveis: Incidentes Que Podem Comprometer a Segurança Dos Pacientes

“…Estudo realizado em Minas Gerais identificou que as unidades de internação apresentaram o maior número (21,1%) de notificação de incidentes (6) . Na região Sul do Brasil, as unidades de internação também foram os locais com maior frequência (64,8%) de notificação de incidentes (7) .…”