Adverse event identification and analysis on pregnant women treated in a level IIIB hospital

Abstract

INTRODUCTION: Incidents are errors and involuntary faults. When they cause harm to the patient during health care, they are called adverse events (AE). The general objective was to describe the AE of pregnant inpatients. More specifically, the study  aimed at determining the incidence, estimating the impact on hospitalization days and severity, describing the causes related  to diagnosis, procedures and administration of medicines, and analyzing the proportion of AE in pregnant women with severe  maternal morbidity (SMM). METHODS: An observational, descriptive and prospective design was used with women admitted  during pregnancy, delivery and postpartum between July and December 2018. Injuries/complications were identified through a  screening form; in positive cases, medical records were evaluated with a modular survey to identify AE and other variables.  RESULTS: A total of 1914 women were included; there were 98 with one or more positive criteria; 42 had an AE (2.19%; 95%CI:  1.58-2.95). There was an increase of hospitalization days in 18 cases, with 19 (45.2%) moderate and 19 (45.2%) severe AE, 24  (57%) diagnostic errors, 24 (57%) of procedure, 11 (26%) related to medications, and 75% of the AE related to SMM. DISCUSSION: The incidence of AE was low, but with a high percentage of serious events. The number of additional  hospitalization days was low. Diagnostic and  procedural errors occurred in more than 50% of the events, with fewer medication  errors. Two out of three patients with SMM suffered an AE.