Analysis of incidents notified in a general hospital

Mirela Lopes de Figueiredo1,2, Carla Silvana de Oliveira E Silva1,2, Maria Fernanda Santos Figueiredo Brito2

  • 1Universidade Federal de São Paulo, Paulista Nursing School, Postgraduate Program in Health Sciences. São Paulo, Brazil.

Abstract

Insights

Patient safety incidents are prevalent in general hospitals, particularly concerning medication. Increased reporting suggests a developing patient safety culture, requiring management attention and protocol adherence.

Area of Science:

  • Healthcare Management
  • Patient Safety
  • Clinical Risk Management

Background:

  • Spontaneous incident reporting is crucial for identifying patient safety risks.
  • Hospitals must proactively monitor and analyze reported incidents to improve care quality.
  • Understanding incident patterns aids in developing targeted safety interventions.

Purpose of the Study:

  • To evaluate the frequency and characteristics of spontaneously reported incidents in a general hospital in Minas Gerais.
  • To identify the main causes and locations of patient safety incidents.
  • To assess trends in incident reporting over a defined period.

Main Methods:

  • Retrospective, descriptive, and quantitative study design.
  • Analysis of 1,316 reported incidents from 2011 to 2014.
  • Descriptive statistical analysis using SPSS v18.0.

Main Results:

  • A prevalence of 33.8 incidents per 1,000 hospitalizations was observed.
  • Incidents were most frequent in hospitalization units, emergency rooms, and surgical centers, primarily affecting adult patients.
  • The medication supply chain was a key area, with noncompliance to routines/protocols as the main cause.

Conclusions:

  • A significant prevalence and increase in incident notifications were noted, highlighting the need for management and staff engagement.
  • Observed increase in reporting indicates a developing patient safety culture within the hospital.
  • Addressing noncompliance with routines and implementing further training are essential for risk reduction.

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