Risk management of adverse events in a maternity hospital

To investigate the root causes of adverse events in a maternity hospital through risk management.

Action research with seven nursing professionals given their expressive capillarity in the service. The study was conducted between January 2020 and February 2021. The field of study was a public maternity hospital, in which a situational diagnosis of adverse events was carried out, and a questionnaire was applied to employees. In the thematic seminars, quality improvement tools were applied to identify the root causes of adverse events. Similar reports were grouped and analyzed.

With risk management, the root causes for adverse events related to patient identification, falls and prescription, use and administration of medications were identified.

Weaknesses were observed in many fields that support adverse events. The institution must adopt consistent investments and collective attention. The study is still ongoing.