Characterization of incidents in a Federal Public Hospital between the years 2014 and 2019




Patient safety; Adverse events; Medical errors; Health goals.


Introduction: the occurrence of incidents in health services can cause serious repercussions for the patient. The fraction of attributable mortality (FAP) of serious adverse events that are preventable was 30.5% in the Unified Health System and 36.1% in the Supplementary Health System. Objective: to characterize the incidents of a reference public federal general hospital in the city of Rio de Janeiro in the period between January 2014 and December 2019. Method: cross-sectional, retrospective and documentary study, carried out from the analysis of notifications. Data collection was carried out between February 10 and 19, 2020. Results: 10.832 were reported in the period between 2014 and 2019. The characterization of the incidents was classified according to the International Patient Safety Goals, adverse events, incidents without damage, almost failure, notifiable circumstances and the item “not applicable”. Final considerations: ensuring identification, prevention and creating solutions to reduce adverse events by establishing procedures for notification, communication and centralized patient involvement, are strategies to improve the quality of care and a step towards a safety culture.


Anderson, O. S. et al. (2013). Surgical adverse events: a systematic review. Am. J Surg. 206(2), 253-62.

ANVISA. (2019). Relatório de Autoavaliação Nacional das Práticas de Segurança do Paciente em Serviços de Saúde. Agência Nacional de Vigilância Sanitária (ANVISA). Ministério da Saúde.

ANVISA. (2020). Sistema Nacional de Notificações em Vigilância Sanitária: Módulo Saúde 2020. Agência Nacional de Vigilância Sanitária (ANVISA). Ministério da Saúde.

Brasil. (2009). Portaria nº 1660 do Ministério da Saúde, de 22 de julho de 2009, instituiu o Sistema de Notificação e Investigação em Vigilância Sanitária, no âmbito do Sistema Nacional de Vigilância Sanitária. Ministério da Saúde.

Brasil. (2009). Portaria nº 529 do Ministério da Saúde de 01 de abril de 2013, instituiu o Programa Nacional de Segurança do Paciente. Ministério da Saúde.

Couto, R. C. et al.(2018). II Anuário da Segurança Assistencial Hospitalar No Brasil. Propondo as prioridades nacionais. Minas Gerais, Brasil: Instituto de Estudos de Saúde Suplementar, 2018.

Comission, J. Sentinel event statistics data – Event type by year (1995–Q2‐2016).

Christopher L. Pysky et al. (2017). A change to the surgical safety checklist to reduce patient identification erros. Ottawa, Canadá: Department of Anesthesiology and Pain Medicine, The Ottawa,Hospital, Faculty of Medicine, University of Ottawa, Ottawa

Institute of Medicine. (2001). Crossing the quality chasm: A new health care system for the 21st century. Japan Council for Quality Health Care, 2017.

Washington, DC: National Academy.

Joint Commission for Patient Safety (2008). World Alliance for Patient Safety.

Jeon. B. S. et al (2019). A facial recognition mobile app for patient safety and biometric identification: design, development, and validation. byoungjun. JMIR Mhealth and Uhealth. 7(4). 8. 2019).

Hoffmeister, V. et al. (2015). Uso de pulseiras de identificação em pacientes internados em um hospital universitário. Revista Latino-Americana de Enfermagem. Universidade de São Paulo.

Lorenzini, E. et al. (2020). Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study. The International Journal of Risk & Safety in Medicine.

NHS. (2018). NRLS. National patient safety incident reports: commentary.

NIHR, (2016). Patient safety translational research centre, Imperial College London. National reporting and learning system research and development. London: Imperial College Healthcare; 2016.

Olino. L. et al. (2019). Comunicação efetiva para a segurança do paciente: nota de transferência e aviso prévio modificado. Revista Gaúcha de Enfermagem. Porto Alegre, Brasil.

Sagawa, M. R., et al. (2019). Análise de circunstâncias notificáveis: incidentes que podem comprometer a segurança dos pacientes. Revista Cogitare Enfermagem. Brasil, Paraná: Universidade Federal do Paraná.

Slawomirski, L, Auraaen, A. & Klazinga, N. (2017). The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. (pp. 23). Paris, França: Organisation for Economic Co-operation and Development.

Walter, M. (2019). Taxonomia em Segurança do paciente: Sousa, P.; Mendes, W. (org.). Segurança do paciente. Conhecendo os riscos nas organizações de saúde. Fundação Oswaldo Cruz – Escola Nacional de Saúde Pública Sergio Arouca

World Health Organization. (2008). Forward programme 2008-2009. World Alliance for Patient Safety.

World Health Organization. (2009). Global Priorities for Patient Safety Research.

World Health Organization. (2009).Safety checklist, patient safety. A World Alliance for Safer Health Care.

World Health Organization. (2009). The conceptual framework for the International classification for patient safety: final technical report. World Alliance for Patient Safety.

World Health Organization. (2012). Research introductory course: What is patient safety. pp. 02. World Alliance for Patient Safety.

World Health Organization. (2017). Challenge on medication safety. Global Patient Safety.



How to Cite

RIBEIRO, A. E. C. .; NOVAES, C. de O. . Characterization of incidents in a Federal Public Hospital between the years 2014 and 2019. Research, Society and Development, [S. l.], v. 10, n. 4, p. e30510414080, 2021. DOI: 10.33448/rsd-v10i4.14080. Disponível em: Acesso em: 7 may. 2021.



Health Sciences