Notificação de eventos adversos: o saber e o fazer de enfermeiros

Nenhuma Miniatura disponível



Título da Revista

ISSN da Revista

Título de Volume


Universidade Federal de Goiás


Introduction: Patient safety has been a topic of discussion in health institutions and the reporting of adverse events is one of the main indicators used to assess the quality of care provided. The nurse, supervisor of the nursing team, has a prominent role in risk management and through the systematic notification of these events should implement preventive strategies for improvements in the quality of care and patient safety. Objective: To analyze nurses' knowledge and performance through the process of reporting adverse events in hospitalized patients. Method: A descriptive, mixed-type cross-sectional study developed at a teaching hospital in the Center-West region of Brazil, with the participation of 60 nurses from the various Clinical Units. Quantitative data were obtained through VIGIHOSP reports, online hospital notification systems, for 2016 and 2017 and analyzed statistically by absolute and relative frequencies. Qualitative data were obtained through interviews with nurses through a structured instrument, in March 2018. The contents of the ATLAS.ti 8.0 software were analyzed and three contents were analyzed: The Nurse's Knowledge; The Making of the Nurse; Intervening factors for the reporting of adverse events. Results and Discussion: In VIGIHOSP, 2495 incidents were reported, the main ones related to surgeries (60.6%) and medications (23.3%). As for surgeries, 98.6% were cancellation of the surgical procedure, being 23.1% due to patient non-attendance, 18.4% due to lack of organizational structure and 15% due to lack of patient's clinical conditions. Of the drug-related incidents, 61.8% were prescription errors and 27.6% dispensing errors. As for the profile of the participants, 46.6% work at night or mixed shift, have more than one employment relationship, working for more than 40 hours a week. It was evidenced underreporting of incidents, since most nurses do not notify the events in the system. Although they reveal knowledge of the institution's event notification system, they do not know its flow, especially regarding the return to the notifier. Factors related to underreporting of incidents were lack of time, lack of professionals / human resources, unavailability of computers for notification and low qualification of some professionals to use the online program. Conclusions: The need for greater investment in nurses' training on the dynamics and flow of the hospital's notification system is evident through continuing education programsinvolving the communication of events as an educational strategy to achieve improvements in the quality of practice care and patient safety.



MOREIRA, I. A. Notificação de eventos adversos: o saber e o fazer de enfermeiros. 2018. 107 f. Dissertação (Mestrado em Saúde Coletiva) - Universidade Federal de Goiás, Goiânia, 2018.