Banca de QUALIFICAÇÃO: CAROLINY VICTORIA DOS SANTOS SILVA

Uma banca de QUALIFICAÇÃO de DOUTORADO foi cadastrada pelo programa.
STUDENT : CAROLINY VICTORIA DOS SANTOS SILVA
DATE: 27/02/2026
TIME: 14:00
LOCAL: Plataforma Teams
TITLE:

Characterization of incident reports in federal teaching hospitals of the Ebserh, Brazil, 2023

KEY WORDS:

“Notification; Patient Safety; Adverse Event; Hospitals University; Health Information Systems Risk Management.

PAGES: 100
BIG AREA: Ciências da Saúde
AREA: Farmácia
SUMMARY:

“Patient safety is one of the central pillars of healthcare quality and remains a persistent challenge for contemporary health systems, particularly in high-complexity institutions such as federal teaching hospitals. Incidents related to healthcare delivery produce significant clinical, organizational, economic, and social impacts, a large proportion of which are preventable. In this context, incident reporting systems play a strategic role by enabling the identification of failures, risk monitoring, and the strengthening of organizational learning. In Brazil, the institutionalization of patient safety has advanced with the creation of the National Patient Safety Program and the implementation of structured surveillance systems, among which the Hospital Health Surveillance System (Vigihosp) stands out. This system is used in federal teaching hospitals within the Ebserh Network. Given this scenario, the present study aims to characterize incident reports recorded in federal teaching hospitals of the Ebserh Network in Brazil in 2023, analyzing the profile of the reported events. This is a descriptive-analytical epidemiological study with a cross-sectional design, based on secondary data obtained from the institutional incident reporting system. The study population comprises all notifications recorded in Vigihosp by federal teaching hospitals affiliated with the Ebserh Network during the study period. The analyzed variables include the profile of notifications, types of incidents, and the distribution of events according to service and patient characteristics. Initially, descriptive analysis was performed to characterize the distribution of incidents according to person, time, and place variables. Subsequently, analytical analysis was conducted using Poisson regression to estimate prevalence ratios and compare the occurrence of incidents between female and male patients, considering sex as the independent variable. Preliminary results indicate a predominance of notifications related to frequent care processes, such as medication errors, falls, healthcareassociated infections, and skin injuries, as well as a high proportion of no-harm incidents and near misses, highlighting the potential of the system as a surveillance and prevention tool. Poisson regression analysis points to statistically significant differences in the distribution of certain types of incidents between women and men, suggesting the influence of biological, care-related, and organizational factors on exposure to care-related risks. Heterogeneity in the notification profile across hospitals within the network was also observed, reflecting structural and organizational variations and differences in the maturity of patient safety culture. The characterization of incident reports reveals recurrent vulnerabilities in care processes and identifies priority areas for institutional interventions, continuing education, and the strengthening of Patient Safety Centers. It is concluded that the analysis of incident reports contributes to expanding knowledge about care-related risks within the context of the Brazilian Unified Health System, supports risk management and clinical governance, and reinforces the importance of the systematic use of reporting data as a tool for continuous improvement in the quality and safety of care.”

COMMITTEE MEMBERS:
Presidente - 1055549 - HELAINE CARNEIRO CAPUCHO
Externa ao Programa - 2165280 - LUIZA DE MARILAC MEIRELES BARBOSA - nullExterna à Instituição - MARIANA MARTINS GONZAGA DO NASCIMENTO - UFMG
Externo à Instituição - YURI GUSTAVO DE SOUSA BARBALHO - UDF