A study of cases reported as incidents in a public hospital from 2011 to 2014


  • Leila Bernarda Donato Göttems Universidade Católica de Brasília
  • Maria do Livramento Gomes dos Santos Universidade Católica de Brasília
  • Paloma Aparecida Carvalho Centro Universitário do Distrito Federal
  • Fábio Ferreira Amorim Escola Superior de Ciências da Saúde




Patient Safety, Risk Management, Quality of Health Care, Health Services Evaluation


OBJECTIVE Analyzing incidents reported in a public hospital in the Federal District, Brasilia, according to the characteristics and outcomes involving patients. METHOD A descriptive and retrospective study of incidents reported between January 2011 and September 2014. RESULTS 209 reported incidents were categorized as reportable occurrences (n = 22, 10.5%), near misses (n = 16, 7.7%); incident without injury (n = 4, 1.9%) and incident with injury (adverse events) (n = 167, 79.9%). The average age of patients was 44 years and the hospitalization time until the moment of the incident was on average 38.5 days. Nurses were the healthcare professionals who most reported the incidents (n = 55, 67%). No outcomes resulted in death. CONCLUSION Incidents related to blood/hemoderivatives, medical devices/equipment, patient injuries and intravenous medication/fluids were the most frequent. Standardizing the reporting processes and enhancing participation by professionals in managing incidents is recommended.


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How to Cite

Göttems, L. B. D., Santos, M. do L. G. dos, Carvalho, P. A., & Amorim, F. F. (2016). A study of cases reported as incidents in a public hospital from 2011 to 2014. Revista Da Escola De Enfermagem Da USP, 50(5), 861-867. https://doi.org/10.1590/s0080-623420160000600021



Original Article