Eventos adversos hospitalares: análise da notificação interna e dos motivos para subnotificação nos sistemas oficiais

Edilaine Coelho  Ferreira; Rafaela Alves Arcanjo; Luana Vieira Toledo; Andreia Guerra Siman

doi:10.15253/2175-6783.20242593160

Authors

Edilaine Coelho Ferreira Universidade Federal de Viçosa https://orcid.org/0000-0003-3323-069X
Rafaela Alves Arcanjo Secretaria de Estado de Saúde de Minas Gerais https://orcid.org/0000-0002-1098-7051
Luana Vieira Toledo Universidade Federal de Viçosa https://orcid.org/0000-0001-9527-7325
Andreia Guerra Siman Universidade Federal de Viçosa https://orcid.org/0000-0001-7990-9273

DOI:

https://doi.org/10.15253/2175-6783.20242593160

Keywords:

Patient Safety; Notification; Underregistration; Health Information Systems; Medical Errors.

Abstract

Objective: to analyze adverse events reported internally in different hospitals and the possible reasons for underreporting to official reporting systems. Methods: a mixed study was carried out in three hospitals, using secondary data from internal records and notifications from official systems. Interviews were conducted with 27 professionals. We used content analysis and statistical analysis of the text corpus using the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires. Results: of the 1,154 adverse events recorded internally, medication/intravenous fluid errors and clinical processes/procedures stand out. However, in the official systems, failure to identify falls appears as the most reported event. The prevalence of underreporting in the official systems was 34.4%, the main reasons being: difficulty of access, lack of knowledge, complexity of the systems, turnover, work overload, internal underreporting, and non-exclusive human resources at the center. Conclusion: The main internal notifications were of medication/intravenous fluid errors and clinical processes/procedures, but there was under-reporting to official systems due to human resources, infrastructure, and management issues. Contributions to practice: the role of managers, professionals, and the regulatory body in implementing actions to facilitate, train, and support those responsible for records stand out.

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