FATORES RELACIONADOS À (SUB) NOTIFICAÇÃO DE EVENTOS ADVERSOS POR PROFISSIONAIS DA TERAPIA INTENSIVA

Abstract

Introduction: The global discussion on the magnitude and social impact of adverse health events has made it essential to analyze the factors related to their incidence to improve care. However, gaps in the identification and reporting persist among multidisciplinary teams in adult intensive care units. Objective: To compare incident triggers in patient records with adverse event reports in adult intensive care units. Method: Exploratory, documentary, multi-method research conducted in an adult intensive care unit of a hospital in southern Brazil from May to October 2024. The sample consisted of medical records selected by simple random sampling and spontaneous adverse event reports submitted to the Patient Safety Center during the study period. The records were analyzed using the Global Trigger Tool. Data were collected by trained nurses, and the listed triggers were reviewed by a team of nurses and a physician. Data were analyzed using descriptive statistics, chi-square test, and logistic regression using R 4.4.0 software. Results: A total of 87 medical records of patients with a mean age of 61.07 years and a median length of stay of three days were analyzed. Triggers and adverse events (AEs) were identified in 85 records (97.7%). A total of 352 triggers were identified, 190 of which were confirmed as AEs. Each additional trigger increased the likelihood of notifications by 30.6%. However, only 10% of the confirmed AEs were reported. A statistically significant association was observed between the occurrence of an adverse event and the following triggers: "cardiorespiratory arrest," "pressure injury," "procedural complications," and "healthcare-associated infections." Of the total number of notifications during this period, 224 reports of AEs involving 98 patients were recorded, with an average of two events per patient. The majority of patients were male (61.2%) and predominantly white or brown (both 46.9%). Spontaneous notifications were more frequent in May and June. The most common events were pressure- or device-related injuries (62.1%), unscheduled device removals (16.1%), and medication failures (6.7%). The root causes were related to method (48.7%) and labor (41.5%), emphasizing communication failures, noncompliance with protocols, and inadequate training. Conclusion: The high rate of underreporting of adverse events highlights the importance of using active surveillance methods, in addition to voluntary reporting, to strengthen the culture of patient safety. Descriptors: Patient Safety. Adverse Event. Intensive Care Unit. Incident Reporting. Nursing.