Analysis of incident reports in information systems for patient safety management.

Abstract

Objectives: to analyze the characteristics of reports of serious incidents and deaths, as well as the improvement actions implemented, considering organizational learning in patient safety management.

Methods: documentary, descriptive, and quantitative research, conducted in a private electronic system for adverse event reports of an accredited organization. Descriptive and inferential statistics were used for association analysis.

Results: reports were mostly from hospital services (98.8%), from the Southeast region (76.7%), from level 1 accredited institutions (36.7%), made after 30 days of the event (49.4%), and occurred with older patients (48.2%). As an organizational consequence of the incidents, there was additional use of resources, treatment, and examinations (54.3%). Among the improvement actions related to professionals, informal guidance stood out (43.9%), and to organizational factors, actions to improve safety culture (31.9%).

Conclusions: the reported events did not present objective information about institutional learning and implementation of actions for care quality and safety.