title: [Adverse events: analysis of a notification instrument used in nursing management].
abstract: The nursing management board of a tertiary university hospital located in Central-South São Paulo state implemented an Adverse Events Notification Instrument in January 2004 aiming at patient safety and at establishing a means of communication between the team and the administration board. The aim of this study was to analyze the use of the referred communication instrument and identify the frequency, type, nature and period of the incident/adverse events. A descriptive data analysis was performed on 826 instruments completed between January 2004 and June 2006. There was compliance to using the instrument. There was predominance of notifications regarding health care services, although there was an increase in reports on administrative issues in the referred period. The most frequent adverse events concerned medications, falls, catheters, probes and drains, and skin integrity. The practicality of the instrument made it feasible for use among nursing aides and technicians. Systematic analysis and follow-up of the adverse events associated with this means of communication appeared as fundamental issues for patient safety.
authors.affiliation: Faculdade de Medicina de Botucatu, Universidade Estadual Paulista "Júlio de Mesquita Filho", Botucatu, SP, Brasil. miriampaiva@fmb.unesp.br
authors.forename: Miriam Cristina Marques da Silva
authors.initials: MC
authors.lastname: de Paiva
authors.forename: Sergio Alberto Rupp
authors.initials: SA
authors.lastname: de Paiva
authors.forename: Heloisa Wey
authors.initials: HW
authors.lastname: Berti
mesh_terms: D003142:Communication; D009729:Nursing; D012189:Retrospective Studies; D017751:Safety Management