title: [Neonatal adverse events and near misses reported in Brazil from 2007 to 2013].
abstract: This study aimed to analyze adverse events and near misses in newborns up to 28 days of life, reported to the Brazilian National Notification System for Sanitary Surveillance (NOTIVISA) system from 2007 to 2013. This was a quantitative, descriptive, retrospective study with analysis of secondary data. A total of 355 incidents were reported: 118 (33.3%) related to medical devices, 4 (1.1%) medical equipment, and 233 (65.6%) medicines. Silver nitrate and antibiotics were the most frequently reported medicines, and among medical devices and equipment, phlebitis associated with IV lines was the most frequently reported adverse event. The study unveils the reporting of adverse events and near misses, fostering discussion on what actually constitutes harm according to the person that reports the event. The challenge for NOTIVISA is to improve the system, and as with other information systems, this results from its use, critical analysis, and interaction with users - incident reporters and interested parties like teaching and research institutions.
authors.affiliation: Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Luciana da Silva
authors.initials: Lda S
authors.lastname: Lanzillotti
authors.affiliation: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Carla Lourenço Tavares de
authors.initials: CL
authors.lastname: Andrade
authors.affiliation: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Walter
authors.initials: W
authors.lastname: Mendes
authors.affiliation: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
authors.forename: Marismary Horsth De
authors.initials: MH
authors.lastname: Seta
mesh_terms: D001938:Brazil; D063005:Health Information Systems / Q000295:instrumentation*; D006801:Humans; D007231:Infant, Newborn; D019300:Medical Errors; D008508:Medication Errors / Q000706:statistics & numerical data; D064406:Patient Harm; D061214:Patient Safety / Q000706:statistics & numerical data*; D012189:Retrospective Studies