National Patient Safety Program in Brazil: Incidents Reported Between 2014 and 2017

Area of Science:

• Public Health
• Healthcare Quality and Safety
• Epidemiology

Background:

• Patient safety is a critical component of healthcare quality.
• Effective reporting systems are essential for identifying and mitigating healthcare risks.
• Understanding incident patterns is key to developing targeted safety interventions.

Purpose of the Study:

• To analyze patient safety incidents reported to the Brazilian National Health Surveillance System between March 2014 and March 2017.
• To identify the types, locations, and severity of reported incidents.
• To examine regional variations in incident reporting across Brazil.

Main Methods:

• Documentary study utilizing records from the Reports of Adverse Events (AE) in Brazil.
• Analysis of variables including incident type, health service, hospital unit, and harm degree.
• Application of analysis of variance and Tukey tests to assess regional differences in incident, AE, and death notifications.

Main Results:

• A total of 109,082 incidents were reported, with 75,088 classified as adverse events (AE) and 649 deaths.
• The most frequent incident categories were 'other' (30.04%) and 'failures during health care' (26.72%).
• Over 93% of incidents occurred in hospitals, particularly in hospitalization and intensive care units. Statistically significant regional differences were observed for incidents, AE, and deaths (P < 0.05).

Conclusions:

• A substantial underreporting of patient safety incidents exists in Brazil.
• Hospitals, especially hospitalization and ICU units, are the primary sites for reported incidents.
• There is a critical need for national, state, and municipal public health policies to enhance supervision, implement Patient Safety Nuclei, and develop protocols based on prevalent incidents.