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Research Article Open access CC BY 4.0

Analysis of Notifications of Incidents Related to Health Care in the State of Pará, during the Covid 19 Pandemic

Dauriane Souza Silva Miranda, Nayara Oliveira Costa, Thais Soares da Silva, Elma Adalgisa Lima Teixeira, Danielle Iasmim Sarmento Pinheiro, Elyson Fernanda Ribeiro da Conceição, Ryane Oliveira Neves, Wênia Gilmara da Silva, Cielma Amaral da Silva, Thayrla dos Santos Duarte, Maria Luisa Freitas Rodrigues Lima, Acsa Lino Geraldo, Perla Katheleen Valente Corrêa, Natasha Cristina Oliveira Andrade, Mayara Annanda Oliveira Neves Kimura

Journal of Advances in Medicine and Medical Research · pp. 248–259 · Published 5 Mar 2025

10.9734/jammr/2025/v37i35761

Abstract

Objective: to analyze the incidents and adverse events related to health care in the State of Pará in the period from 2020 to 2021, registered in the National Notification Program for Health Surveillance (NOTIVISA). Methods: This is a cross-sectional study with a quantitative approach, using secondary data recorded in NOTIVISA, published and made available on the ANVISA website. Results: it was possible to verify during the study period that the state of Pará recorded 498 notifications of incidents related to health care in the period from 2020 to 2021 to NOTIVISA. The most notified and highlighted types of events were during health care with 201 notifications (40.36%). Of the incidents recorded, the majority occurred in hospitals, with 199 (42.16%) notifications involving failures during health care. Regarding the outpatient service, we highlight the incident Patients Accidents (3) (0.64%) and Patient Fall (2) (0.42%). In other types of services, failures during health care were the most notified event, with 2 records (0.42%). In the clinics, the reported incidents were Bronchoaspiration and Failures in the administration of O2 or medicinal gases, both with 1 notification (0.21%). In the types of damage, Light Damage stood out with 288 notifications (57.83%), followed by No damage with 82 notifications (16.47%), Moderate damage with 77 records (15.46%), Death with 28 records (5.62%) and Severe with 23 notifications (4.62%). Incidents by age group show that adults aged 56 to 65 years were the most affected, with 85 records (17.07%). In relation to pediatrics, the age group of less than 28 days was the one that obtained the highest number of notifications, with 33 records (6.63%). Reported deaths were highlighted in Failures during Health Care (23) (82.14%). The most notified never events were Stage III Pressure Injury (PPL), with 7 notifications (87.50%). Conclusion: between 2020 and 2021, NOTIVISA recorded only 498 notifications of health-related incidents in the state. Being a problem of great proportion in Pará, due to the deficit in the recognition of injuries and limitation in the practice of notifying, consequently, the number of records is well below expected.

Incidents adverse events health care patient safety

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