The feature of preventable adverse events in hospitals in the State of Rio de Janeiro, Brazil

Objective

To analyze the features of preventable adverse events (AEs) in hospitals inpatient in the state of Rio de Janeiro, in Brazil, in order to identify elements to serve as a substrate for priority actions aimed at improving patient safety.

Methods

Analysis of data from a baseline retrospective cohort study to assess the incidence of AEs in a sample of records in three teaching hospitals in the State of Rio de Janeiro to describe the features of preventable AEs.

Results

In a sample of 1,103 patients, were identified 65 preventable AEs of 56 patients who suffered preventable AEs. The healthcare associated infections (HAI) accounted for 24.6% of preventable AEs; surgical complications and/or anesthetic, 20.0%; damages arising from delay or failure in diagnosis and/or treatment, 18.4%; pressure ulcers, 18.4%; damage from complications of venipuncture, 7.7%; damage due to falls, 6.2%; damage as a result of the use of drugs, 4.6%. The preventable AEs were responsible for additional 373 days of hospital stay.

Conclusion

The HAI is the major preventable AE, as observed in other developing countries. Despite the limitations of the study, the characterization of preventable AEs indicates that known and effective actions available to reduce HAI, such as hand hygiene, to prevent pressure ulcers, to encourage adherence to protocol and clinical guidelines and to create continuing education programs for health professionals, should compose the list of priorities of hospital managers and health professionals involved in the care of hospitalized patients.