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Observational Study
. 2023 Jul 10;76(3):e20220025.
doi: 10.1590/0034-7167-2022-0025. eCollection 2023.

Occurrence and preventability of adverse events in hospitals: a retrospective study

[Article in English, Portuguese]
Antônio José de Lima Júnior  1 , Ariane Cristina Barboza Zanetti  1 , Bruna Moreno Dias  1 , Andrea Bernardes  1 , Francielly Marques Gastaldi  2 , Carmen Silvia Gabriel  1
Affiliations
Observational Study

Occurrence and preventability of adverse events in hospitals: a retrospective study

[Article in English, Portuguese]
Antônio José de Lima Júnior et al. Rev Bras Enferm. .

Abstract
in English, Portuguese, Spanish

Objectives: to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.

Methods: observational, analytical, retrospective study based on medical records review.

Results: medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.

Conclusions: this study's results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.

Objetivos:: analisar a incidência de eventos adversos evitáveis relacionados ao cuidado em saúde em pacientes adultos internados em hospitais públicos brasileiros.

Métodos:: estudo observacional, analítico, de corte retrospectivo, baseado na revisão de prontuários.

Resultados:: avaliaram-se prontuários de 370 pacientes, dos quais 58 sofreram pelo menos um evento adverso. A incidência de eventos adversos correspondeu a 15,7%. Os eventos adversos foram vinculados: à infecção relacionada à assistência à saúde (47,1%) e a procedimentos (24,5%), predominantemente. No que tange à gravidade dos eventos adversos, averiguou-se que 13,7% foram considerados leves, 51,0%, moderados e 35,3%, graves. Classificou-se como evitáveis 99% dos eventos adversos. Pacientes internados em caráter de urgência apresentaram risco 3,73 vezes maior para a ocorrência de um evento adverso.

Conclusões:: os resultados deste estudo apontam elevada incidência de eventos adversos evitáveis e contribuem para evidenciar a necessidade de intervenções na prática assistencial.

Objetivos:: analizar la incidencia de eventos adversos evitables relacionados al cuidado de la salud en pacientes adultos internados en hospitales públicos brasileños.

Métodos:: estudio observacional, analítico, retrospectivo, basado en la revisión de historias clínicas.

Resultados:: se evaluaron las historias clínicas de 370 pacientes, 58 de los cuales sufrieron al menos un evento adverso. La incidencia de eventos adversos correspondió al 15,7%. Los eventos adversos estaban relacionados, principalmente, con: infecciones por asistencia sanitaria (47,1%) y procedimientos (24,5%). Respecto a la gravedad de los eventos adversos, el 13,7% era leve, el 51%, moderado y el 35,3%, grave. Se clasificó como evitable el 99% de los eventos adversos. Los pacientes ingresados en urgencias presentaron un riesgo 3,73 veces mayor de aparición de eventos adversos.

Conclusiones:: los resultados de este estudio señalan una incidencia elevada de eventos adversos evitables y resaltan la necesidad de intervenciones en la práctica asistencial.

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Figures

Figure 1
Figure 1. Flow of retrospective medical record review
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References

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