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

Rev Assoc Med Bras (1992). Sep-Oct 2013;59(5):421-8. doi: 10.1016/j.ramb.2013.03.002. Epub 2013 Sep 12.
[Article in English, Portuguese]


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 that 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 AEs, 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.

Keywords: Evento adverso evitável; Health care quality; Hospitais; Hospitals; Patient safety; Preventable adverse event; Qualidade da assistência à saúde; Segurança do paciente.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Brazil
  • Cohort Studies
  • Delayed Diagnosis / statistics & numerical data
  • Female
  • Hospitals, Teaching*
  • Humans
  • Length of Stay
  • Male
  • Medical Errors / statistics & numerical data*
  • Medication Errors / statistics & numerical data
  • Middle Aged
  • Quality Indicators, Health Care
  • Retrospective Studies
  • Risk Management
  • Young Adult