Incidentes notificados no cuidado obstétrico de um hospital público e fatores associados

Abstract

Introduction: Patient safety seeks to reduce, to na acceptable minimum, the risk of unnecessary harm associated with health care. Regarding maternal and neonatal care, quality and safety have also occupied the agenda of Brazilian public policies intensively as a strategy for reducing perinatal morbidity and mortality. Objective: To analyze the incidents related to obstetric care reported in a public hospital according to the profile of the women involved and factors associated with serious adverse events. Method: A cross-sectional, retrospective study with incidents recorded in the Incident Reporting System of a public hospital in Federal District specialized in maternal and child care between 2015 and 2017. A logistic regression in one model, with subsequent adjustment of variables in a multiple model, was used to evaluate the factors associated with severe adverse events. Results: A total of 114 incidents were reported, of which 104 occurred in patients and resulted in mild (16.7%), moderate (32.5%) and severe (24.5%) injuries, with 4.8% of deaths related to the incident. The majority of the incidents occurred during the day (75.3%), in the Obstetric Center (51.7%), were notified by nurses (57.0%) and were related to health care procedures (48.3%). Serious adverse events were more likely to occur at the Obstetric Center (OR = 3.86, 95%CI 1.26–11.84) and at night (OR = 3.37, 95%CI 1.16–9.75). Conclusions: Most incidents caused moderate or severe damage to patients. Serious events were more likely to occur at the Obstetric Center and at night.