Notificação de eventos adversos cirúrgicos em um hospital universitário: instrumento de avaliação da qualidade

Abstract

Adverse events are undesirable and unfavorable occurrences that contribute to increased morbidity and mortality in pacientes undergoing surgical procedures, impacting their clinical outcome. The objective of the study was to identify the main reports of perioperative incidents and adverse events that occurred at the Hospital Universitário Getúlio Vargas (HUGV/UFAM) between March/2015 and June/2021. A single-center, analytical, observational and retrospective study was carried out, with approval from the Research Ethics Committee of the Federal University of Amazonas (CAAE: 51016521.2.0000.5020). A total of 100 participants were included in the study, who generated one or more reports of incidents or adverse events. The study patients were mostly female (55%), aged between 50-60 years, with ASA II risk classification (37%), undergoing major surgery (45%) under balanced general anesthesia (44%), with incidents related to the use of inappropriate material for the procedure (25%). In 92% of cases, the incident occurred in the operating room, and it was classified as assistance in 66% of cases, with 57.4% risk of complications. The adverse events recorded in the medical records analyzed were mostly preventable, and were related to carrê provided by the multidisciplinary team. From the analysis of the data obtained in the research, flowcharts will be established to control adverse events, aiming at improving the provision of service to patients treated at the university hospital.