ISQUA16-2853ANALYSIS OF PATIENT SAFETY INCIDENTS IN BRAZILIAN ACCREDITED HOSPITALS - THE SAFETY SENTINEL PROJECT:

Abstract

Objectives: The objective of this study was to identify critical points concerning patient safety through the analysis of a database with compiled incident notifications from 107 health organizations in Brazil. Method(s): Since 2002 IQG - Health Services Accreditation (IQG) follows the voluntary reporting of patient safety incidents, carried out by Brazilian accredited institutions. In 2014 the Brazilian Patient Safety Program (PBSP) team began to conduct this process, improving the communication channels, aiming to strengthen the safety and learning net, prioritize critical points concerning patient safety, identify intervention strategies, and promote best practices in incident analysis. Healthcare organizations voluntarily report the safety incidents detected and the plan designed to reduce risks and prevent recurrence. The incidents are classified by incident type and patient outcomes and the analysis focus on identifying contributing factors and hazards. The PBSP technical team evaluates the incident analysis reported by the organization, and gives a feedback by phone or e-mail on the assertiveness and maturity of the analysis and effectiveness of the proposed plan of action. The technical team also publishes quarterly reports on the incident analysis database, and holds web based conferences for the discussion of the most frequently identified contributing factors and hazards. Result(s): From 2012 to 2015 the Brazilian Patient Safety Program received 13,316 patient safety incident notifications, from 107 healthcare organizations across all regions of Brazil, including acute care hospitals, ambulatories, oncology centres, hematology and blood bank centres, clinical laboratories and imaging diagnostic centres. We noticed a significant increase in the number of reported incidents in the period of 2012 to 2015. Observing the reported incidents classified by patient outcome, the increase is both evident among harmful incidents and no harm incidents as can be seen on the table below. The number of near misses reported is not significant yet. (Table presented) When analysing the group of Harmful Incidents that resulted in death, 40% happened in hospitals wards, 23% in emergency departments, 15% In intensive care units, 7% in operating rooms, 5% in imaging diagnostic units. In 39% of these harmful incidents that resulted in death, the delay in the detection of clinical deterioration (including delay in sepsis diagnosing) and initiation of clinical response were identified as major contributing factors. Conclusion(s): The increase in the number of patient safety incidents reported show that the contact with the technical staff for support and guidance and the communication channels used (via phone, email and web conferences) were able to cross the continental distances inside Brazil and raise awareness and perception for patient safety. It also suggests that the feedback was positive for the organizations. The necessity to review health professionals work dynamics, especially in hospital wards, regarding assessment of acute illness, detection of clinical deterioration and initiation of a timely and competent clinical response is supported by the analysis of the units were severe incidents occurred and the contributing factors identified.