Notificação de eventos adversos cirúrgicos em um hospital universitário: estudo transversal
DOI:
https://doi.org/10.60104/revhugv12743Keywords:
Adverse events, mortality, morbidity, surgery, perioperative safetyAbstract
Adverse events are undesirable and unfavorable occurrences that contribute to morbidity and mortality in patients undergoing surgical procedures, impacting their clinical outcome. The objective of the study was to analyze notifications of perioperative incidents that occurred at the Hospital Universitário Getúlio Vargas (HUGV/UFAM) between March/2015 and June/2021. This is a descriptive and exploratory research with a quantitative approach, based on secondary data from incident notifications related to health care, recorded in the Health Surveillance and Hospital Care Risk Management System - Vigihosp. This study was approved by the Research Ethics Committee of the Federal University of Amazonas (CAAE: 51016521.2.0000.5020). During the research period, 100 notifications of incidents or adverse events were registered in the surgery module of the Vigihosp system, containing data about the patient and the incident, such as classification, contributing and mitigating factors and improvement actions, according to the notifier's perception. Reports were mostly female patients (55%), aged between 50-60 years, with ASA II risk classification (37%), undergoing major surgery (45%) with general anesthesia balanced (44%). Regarding the location, they were more frequent in the operating room (92%) and classified as care in 66% of cases. The detection of inadequate material for the procedure (25%), care failure (23%) and inadequate preparation of the patient (22%) stood out. As for the outcome of the notifications received, 42,6% of the participants evolved without complications and in 57.4% of the cases events were reported, such as surgical site infection (13,1%), increased length of stay (11,1 %) and surgical time (9,3%), with fatal outcome in 5,6% of cases. Adverse events recorded in the medical records were mostly preventable, and the implementation of damage prevention measures in the institution can promote an increase in the patient's safety culture.
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