Patient safety incidents occurred during nursing care

Heloisa Helena Karnas Hoefel, Isabel Echer, Amália de Fátima Lucena, Vanessa Monteiro Mantovani


Background and Objectives: Patient safety is a worldwide concern that has been highlighted in recent years and its study subsidizes preventive actions. The objective was to analyze patient safety incidents that occurred during nursing care. Methods: This was a retrospective, descriptive-exploratory documentary study carried out at a university hospital in southern Brazil. The documents related to patient safety incidents occurred during nursing care at the institution were classified and analyzed. Results: A total of 82 incidents were analyzed, of which 43 (52%) were classified as adverse events and 39 (48%) as incidents without harmful consequences. In 53 (64%) cases, the causes of the incidents occurred due to errors, 14 (17%) due to violations and 15 (18%) due to system failure. Incidents related to technical procedures were responsible for 67 (82%) occurrences, and adverse events occurred in 38 (57%) of them. Conclusion: Incidents causing both adverse events and those with no harmful consequences during care were identified, mostly caused by errors, followed by violations or system failures.


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