Incidentes relacionados ao cuidado obstetrício e proposta de protocolo para notificação de incidentes na rede pública do Distrito Federal

Abstract

Introduction: Patient safety has been a topic discussed worldwide since the publication of the Institute of Medicine’s report To Err is Human: Building a Safer Health System, in 1999. Among the various repercussions, the document highlighted the impact of adverse events on mortality and the length of hospital stay. Despite the scarcity of analyzes of incidents in obstetric care, high rates of perinatal morbidity and mortality are observed in Brazil. Therefore, research that analyzes the incidents occurring in the hospital context and its characteristics, as well as the elaboration of a protocol that systematizes the notification process, is highly relevant. Objectives: To analyze incidents related to obstetric care reported in a public hospital in the Federal District and to develop a proposal for an incident notification protocol for the Public Network of the Federal District. Methods: For the article, an analytical and retrospective transversal study was carried out. Data collected in the Incident Reporting System and in medical records. Incidents from January 2015 to June 2017, in a public hospital specializing in maternal and child care. For the protocol, a bibliographic survey was carried out in publications with guidelines and guidelines of the Ministry of Health, in a State Plan for Health Management of Patient Safety in Health Services, and in protocols, records and flowcharts of notification in several SES/DF hospitals. in other states of Brazil; and protocol discussion and validation meetings in conjunction with other Patient Quality and Safety Centers of the Federal District. Results: In the study, of the 104 incidents analyzed, the average age was 28.2 years (± 7.6), the average length of stay of 14 days (± 16.4), 53.5% nulliparous, 47.3% term pregnancy, 49.5% in hospitalization related to cesarean delivery and 33%, normal delivery. Of the reported incidents, 64% occurred during the day, 48.2% referred to health care procedures, in the Obstetric Center (33.3%) and the Intensive Care Unit (30.7%). The damages were mild (16.3%), moderate (32.5%) and severe (24.6%); and in 26.3%, there was no harm to the patient. Statistical significance was observed between severe adverse events and the local (p = 0.018) and shift (p = 0.025) of occurrence. The protocol describes the phases of notification and management of incidents and adverse events. Conclusion: The understanding of the characteristics of the reported incidents subsidized the planning of specific and effective actions to promote safer obstetric care: some interventions in the local notification form, educational materials with the subject of patient safety, safe medication, safe surgery and childbirth insurance. Two products were prepared: an article entitled “Analysis of the incidents related to obstetric care reported in a public hospital”, submitted for publication in the Brazilian Journal of Maternal and Child Health and a Proposal for an Incident Report Protocol, which may be included in the District Patient Safety Policy, to be launched in 2018.