Eventos adversos que evoluíram para óbito em hospitais públicos universitários do Brasil e condutas adotadas para evitar recorrência

Abstract

Objective: to analyze the voluntary notifications of suspected adverse events related to health care that evolved to death and the actions taken to avoid recurrence based on the information from the notifications registered by public university hospitals (HPU) in Brazil, from 2014 to 2019. Method: For the development of the article, a retrospective study was carried out that analyzed notifications of suspected adverse events that resulted in death, registered by 35 hospitals, distributed in the five Brazilian regions. The type of incident reported, place of occurrence, age group and gender of individuals who suffered events, professional category of the notifier and the actions taken in the event were analyzed. After the analysis of the adopted actions, a proposal was made for a protocol of actions against adverse events resulting in death, based on the Protocol Model of the Brazilian Company of Hospital Services (EBSERH), containing mandatory items, following the steps: literature review, meeting with the responsible area of the Company, review and validation of the Company and publication in the Service Bulletin. Results: 132,700 incidents related to health care were recorded in the period, with 14% causing some type of harm to patients and 0.8% progressing to death. The most affected individuals were males (51%) and those over 60 years of age (30%). Nursing was the category that most reported notifications (77%). In 12% of the events, the London Protocol was applied and the average time taken to complete an investigation was 161 days. Based on the findings, the following were developed: an Original Article submitted, on December 11, 2021, to the Revista Latino Americana de Enfermagem containing the analysis of suspected reports of adverse events related to health care; and a Protocol of actions in the face of adverse events resulting in death to guide the conduct in accordance with national regulations and good national and international practices in patient safety, to avoid the recurrence of adverse events. This protocol is being evaluated by the EBSERH Legal Consultancy, for later publication. Conclusion: the study demonstrated a significant lethality and the need to improve improvement actions. The establishment of the protocol aims to standardize actions, comply with the legislation of the National Health Surveillance System and avoid the recurrence of adverse events.