# Frequency and content analysis of adverse event reports in surgical centers: a cross-sectional study

## TL;DR

This study analyzed adverse event reports in surgical centers to determine their frequency and content, revealing common issues like pressure injuries and underreporting.

## Contribution

The study provides insights into the types and frequency of adverse events in surgical centers, highlighting underreporting and lack of standardization.

## Key findings

- Sixteen never events were identified, including pressure injuries and incorrect surgical procedures.
- Pressure injuries, burns, organ damage, and surgical site infections were the most frequent adverse events reported.
- Underreporting and lack of standardization in reporting were significant issues identified in the study.

## Abstract

to identify the frequency of adverse events reported in surgical centers and analyze the content of the reports made.

a cross-sectional study analyzed reports from January 2019 to March 2023 in eight hospitals, with a sample of 163 reports. The quantitative analysis considered variables such as type and degree of damage, while the qualitative analysis used similarity analysis in Iramuteq.

sixteen never events were identified, including pressure injuries (stages three and four), loss of biopsy material, incorrect surgical procedures, and unintentional retention of a foreign body. The qualitative analysis highlighted terms such as “failures in care”, “failure”, “surgical procedure”, and “pressure injury”.

pressure injuries, burns, organ damage, and surgical site infection were the most frequent reports. There is underreporting of adverse events in surgical centers and limitations in the quality of records, including unspecified adverse events and lack of standardization in reporting.

identificar a frequência de eventos adversos notificados em centros cirúrgicos e analisar o conteúdo das notificações realizadas.

estudo transversal analisou notificações de janeiro de 2019 a março de 2023 em oito hospitais, com uma amostra de 163 notificações. A análise quantitativa considerou variáveis como tipo e grau do dano, enquanto a qualitativa utilizou análise de similitude no Iramuteq.

foram identificados dezesseis never events, incluindo lesões por pressão (estágios três e quatro), perda de material para biópsia, procedimentos cirúrgicos incorretos e retenção não intencional de corpo estranho. A análise qualitativa destacou termos como “falhas na assistência”, “falha”, “procedimento cirúrgico” e “lesão por pressão”.

lesões por pressão, queimaduras, lesão de órgão e infecção de sítio cirúrgico foram as notificações mais frequentes. Há subnotificação de eventos adversos em centros cirúrgicos e limitações na qualidade dos registros, incluindo eventos adversos não especificados e ausência de padronização no relato.