Occurrence and preventability of adverse events in hospitals: a retrospective study.
Antônio José de Lima Júnior, Ariane Cristina Barboza Zanetti, Bruna Moreno Dias and 3 others
PMID 37436233WHAT IT FOUND
In Brazilian public hospitals, 15.7% of adult inpatients experienced adverse events, with 99% deemed preventable.
Urgent admissions carried nearly four times the risk of elective ones. Healthcare-associated infections were the most common cause, accounting for nearly half of all events.
Key findings
0115.7% of patients experienced adverse events, and 99% of these were classified as preventable.
02Patients admitted urgently had approximately four times higher risk of adverse events compared to those admitted electively.
03Healthcare-associated infections were the primary driver of adverse events, responsible for 47.1% of cases.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study relied on retrospective chart reviews, meaning findings are limited by the quality and completeness of medical records. The sample was drawn from only two public teaching hospitals in one Brazilian city, which may limit generalizability to other settings. Assessing preventability involved subjective judgment by reviewers, which could introduce bias. The extremely high preventability rate (99%) differs significantly from other international studies, suggesting potential issues with the evaluation criteria or implementation.
Declared interests
The study was approved by Research Ethics Committees. No specific funding sources or conflicts of interest were declared in the provided text.
The easy way to misread this
Do not interpret the 99% preventability rate as a universal statistic for all hospitals. This figure is markedly higher than international norms and may reflect the specific subjective criteria used by the reviewers or limitations in the retrospective chart review method.