Subnotificação de eventos adversos e incidentes sem danos em unidade de terapia intensiva adulto

Abstract

Estimates say that one in 10 patients is a victim of some incident without harm or adverse event during health care. It is also believed that around three million people die each year as a result of these events. Considering the importance of patient safety and incident notification, it is necessary to know how often they occur and which incidents occur most in the environment, in order to identify problems in the recording of these events. Thus, the question was: What is the profile of adverse events and incidents without damage that occur in an adult Intensive Care Unit and their notification to the Patient Safety Center? *It aimed to assess whether adverse events and incidents without harm that occurred in an adult Intensive Care Unit and recorded in medical records were notified to the patient safety unit.* Descriptive study of document analysis, in electronic medical records and printed notification forms from the Patient Safety Center. It was carried out in the Intensive Care Unit of a private hospital in the Midwest of Brazil. The study population consisted of electronic medical records of patients admitted to clinical and surgical Intensive Care Units and incident and adverse event records reported to the hospital's patient safety unit. The determination of the sample was made from the total count of medical records during the period with a sampling error of 5% and a confidence rate of 90%. The sample consisted of 207 medical records, which were randomly selected. The notification forms referring to the ICU were analyzed in their entirety. Medical records of patients hospitalized from January 2019 to January 2020, aged 18 years or over, with a hospital stay of more than 24 hours, were included. Notification forms referring to the Intensive Care Unit typed in spreadsheets, separated by the patient safety unit, which were related to the Intensive Care Unit, were included. Medical records that presented incomplete records were excluded. Data were collected by the researcher and three previously trained final-year undergraduate nursing students. Data collection took place from November to December 2020. 207 medical records were analyzed and 140 records of incidents were found by the multidisciplinary team. Of these, 127 had harm to the patient, characterized as adverse events, 12 were incidents without harm and 1 was Near Miss (Potential Adverse Event). The most frequent incidents were: Failure during procedure or approach (29/20.7%), followed by Infections Related to Health Care (28/20.0%) and Nutritional Therapy (24/17.1%). During the study period, 74 notifications were found referring to the ICU sector at the Patient Safety Center. However, of these, only one of the incidents was reported in the patient's medical record, evidencing the underreporting of 139 incidents. This underreporting makes it difficult to understand the magnitude of the problem and to implement strategies aimed at improving patient safety