From the Department of Life Sciences, Bahia State University.
Department of Health Sciences, Federal University of Espírito Santo, Espírito Santo.
J Patient Saf. 2021 Dec 1;17(8):e1202-e1208. doi: 10.1097/PTS.0000000000000496.
The aim of the study was to analyze the patient safety incidents reported to the Brazilian National Health Surveillance System from March 2014 to March 2017.
A documentary study that used the records of the incidents published in the Reports of Adverse Events (AE) in Brazil. The following variables were selected: number of incidents by type, type of health service, hospital unit, and degree of harm. To find whether there was a significant difference across the Brazilian regions by notifications related to general incidents, AE, and deaths, the analysis of variance and the Tukey tests were used.
A total of 109,082 incidents were reported, of which 75,088 were AE, with 649 deaths. In relation to the types of incidents reported, there was a higher frequency in the categories other (30.04%) and failures during health care (26.72%). A total of 93.90% of the incidents occurred in hospitals, with 54,950 cases registered in hospitalization units and 30,141 cases in intensive care units. Statistically significant differences across the Brazilian regions were observed in the number of incidents (P = 0.004), AE (P = 0.004), and deaths (P = 0.024).
A significant underreporting of incidents was found in Brazil, demonstrating only the tip of a giant iceberg. More than half of the incidents were reported as AE and were registered in hospitals, reiterating the importance of establishing public health policies at national, state, and municipal levels, with adequate supervision of the health service regarding the implementation of the Patient Safety Nuclei and the preparation of new protocols based on the most prevalent incidents.
本研究旨在分析 2014 年 3 月至 2017 年 3 月向巴西国家卫生监督系统报告的患者安全事件。
本研究为文献回顾性研究，使用了在巴西不良事件报告中发表的事件记录。选择了以下变量：按类型、卫生服务类型、医院科室和伤害程度分类的事件数量。为了发现与一般事件、不良事件和死亡相关的通知在巴西各地区之间是否存在显著差异，采用方差分析和 Tukey 检验。
共报告了 109082 起事件，其中 75088 起为不良事件，有 649 例死亡。就报告的事件类型而言，其他类型（30.04%）和医疗保健失败（26.72%）的发生率较高。报告的事件 93.90%发生在医院，其中住院科室登记了 54950 例，重症监护室登记了 30141 例。巴西各地区的事件数量（P=0.004）、不良事件（P=0.004）和死亡（P=0.024）存在统计学差异。
巴西发现了大量事件的漏报，这表明这只是冰山一角。超过一半的事件被报告为不良事件，并在医院登记，这再次强调了在国家、州和市级层面制定公共卫生政策的重要性，对卫生服务进行适当监督，实施患者安全核心，并根据最常见的事件制定新的协议。
