Risk management of adverse events in a maternity hospital

Action research with seven nursing professionals given their expressive capillarity in the service. The study was conducted between January 2020 and February 2021. The field of study was a public maternity hospital, in which a situational diagnosis of adverse events was carried out, and a questionnaire was applied to employees. In the thematic seminars, quality improvement tools were applied to identify the root causes of adverse events. Similar reports were grouped and analyzed.

Results:

With risk management, the root causes for adverse events related to patient identification, falls and prescription, use and administration of medications were identified.

Final considerations:

Weaknesses were observed in many fields that support adverse events. The institution must adopt consistent investments and collective attention. The study is still ongoing.

Keywords:
Health services; Patient safety; Risk management; Safety management; Nursing

Incident/Adverse Events	N=274	%
Errors related to patient identification	58	21.1
Falls	40	14.6
Drug-related errors	27	9.8
Patient evasion	14	5.1
Phlebitis	11	4.0
Pressure injury	8	2.9
Accidental extubation	6	2.2
Unprogrammed removal of catheters, probes, drains, tube	5	1.8
Error related to surgical procedure	4	1.4
Risks related to the environment	4	1.4
Screening not performed-incomplete-inappropriate	4	1.4
Technovigilance	3	1.1
Suffering (physical, psychic, social)	2	0.7
Error related to blood products transfusion	1	0.4
Ignored	17	6.2
Others*	70	25.9

Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
E-mail: revista@enf.ufrgs.br

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[1] Corresponding author:
Rafael Carvalho de Maria E-mail: rafaelrosely@hotmail.com

Adverse events	Material	Organizational	Environment	Processes	Patients	People
Patient identification	¹Shortage of materials.	¹Deficit of supplies needed to identify patients. ²Inadequate sizing. ³Punitive culture. ⁴Irregularity in the qualification of the team.	¹Environment with insufficient lighting.	¹Failure patient identification process.	¹Patients not included as collaborator in the protocol.	¹Professionals with low qualifications in the process. ²Overwork. ³Inattention.
Falls	¹Shortage and/or inadequacy of materials.	¹Workflow not clearly established. ²Irregularity in the qualification of the team.	¹Environment poorly adapted to prevent falls.	¹Failure fall prevention process.	¹Patients not included as collaborators in the protocol.	¹Professionals with low qualifications in the fall prevention protocol and Morse scale.
Medication^*	¹Shortage of supplies and materials. ²Poor quality materials.	¹Lack of training on medications. ²Inadequate sizing.	¹Environment poorly adapted for preparing and administering medications.	¹Process of prescription, use and administration of medicines with failures.	¹Patients not included as collaborators in the protocol of prescription, use and administration of medications.	¹Professionals with low qualifications in the protocol of prescription, use and administration of medications. ²Overworked professionals.