Gestão de riscos dos incidentes e eventos adversos em hospital público do município de Caxias-MA

Abstract

Patient safety encompasses a set of measures developed to promote the reduction of incidents in health facilities, with or without damage (adverse event). In order to contribute to the process of evaluating health behaviors and provide strategies that make it possible to identify potential vulnerabilities in the practice of the nursing team, the general objective of this study was to investigate the circumstances surrounding incidents and adverse events in a public hospital through the risk management. This is a descriptive action research with a qualitative approach in a public hospital in the city of Caxias, Maranhão, with the nursing team. Action research includes four well-defined phases: planning, action, description and evaluation. The data collection period was from October 2019 to October 2022 and the data analysis was based on the Lean philosophy, which focuses on promoting a broad view of the system. In three years of operation, the 2017-2019 Patient Safety Center accounted for 1,631 reports of incidents and adverse events, in which 8.4% occurred in administrative activities, 46.2% during patient care and protection, 0.7 % in administering diets, 1.7% due to falls, 18.2% patient accidents, 6.8% related to patient identification, 8.7% represented Pressure Injury and 6.8% related to medications. Based on this situational diagnosis, it was possible to select the main incidents and adverse events related to health care at the selected hospital, and these were discussed in the thematic seminars to obtain possible root causes, with the help of the Brainstorming technique linked to the “5 why’s”, and strategies formulated together with professionals through the Ishikawa diagram, obtaining relevant information for risk management. From the data collected and the seminars, it can be understood that incidents and adverse events related to health care are a structural problem, but that can be circumvented through risk management and consequente promotion of a safety culture, so that professionals not only learn from mistakes, but that the institution guarantees permanent education that qualifies the assistance offered.