Adverse events related to foreign body retention
DOI:
https://doi.org/10.26694/reufpi.v14i1.6364Keywords:
Near miss, healthcare, Time out, healthcare, Sentinel surveillance, Patient safety, Guideline adherenceAbstract
Objective: to analyze events related to foreign body retention recorded in a healthcare institution and to describe the process of reformulating the prevention protocol. Methodology: observational, descriptive, and retrospective study based on all adverse event notifications between 2021 and 2022. The outcomes of the change in the institutional protocol on the incidence of foreign body retention in a large, private, philanthropic hospital were analyzed. Data were extracted and analyzed with a focus on notified adverse events, observing possible changes in the number of occurrences after the implementation of the new protocol. Results: in the year 2021, 14,370 surgical procedures were performed, with four cases of retention notified, a rate of 0.02%. In the year 2022, 17,920 surgical procedures were performed, with five cases of retention, maintaining the same rate of 0.02%. The cases involved needles, gauzes, and instruments, without evidence of reduction after the implementation of the new protocol. Conclusion: despite the low incidence observed, retention is an adverse event with serious consequences for patients and significant losses for institutions. It is essential to carefully analyze the causes of failure to adhere to the protocol and invest in continuous training to strengthen safety culture.
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