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Analysis of incident reports in information systems for patient safety management
Renata Lima Gonçalves Caroccini1, Geisa Colebrusco de Souza Gonçalves1, Elena Bohomol1
1Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil.
Objectives:
to analyze the characteristics of reports of serious incidents and deaths, as well as the improvement actions implemented, considering organizational learning in patient safety management.
Methods:
documentary, descriptive, and quantitative research, conducted in a private electronic system for adverse event reports of an accredited organization. Descriptive and inferential statistics were used for association analysis.
Results:
reports were mostly from hospital services (98.8%), from the Southeast region (76.7%), from level 1 accredited institutions (36.7%), made after 30 days of the event (49.4%), and occurred with older patients (48.2%). As an organizational consequence of the incidents, there was additional use of resources, treatment, and examinations (54.3%). Among the improvement actions related to professionals, informal guidance stood out (43.9%), and to organizational factors, actions to improve safety culture (31.9%).
Conclusions:
the reported events did not present objective information about institutional learning and implementation of actions for care quality and safety.
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