Segurança do paciente em hospitais brasileiros: uma análise documental (2014–2023)

Abstract

Introduction: Created in 2013, the National Patient Safety Program (PNSP) aims to contribute to improving the quality of care in healthcare facilities. Objective: To analyze patient safety (PS) in hospitals in Brazil, considering the monitoring of incident reports and the National Assessments of PS Practices and PS Culture conducted by Anvisa. Method: A retrospective documentary study was conducted from 2014 to 2023 using data from Anvisa. Absolute frequencies and measures of central tendency and dispersion were calculated. Results: The annual number of notifications increased from 8,009 to 340,606, showing an upward trend (β: 35,145.3; CI (28,301.1–41,989.6); R² = 0.946). During the analyzed period, 30,145 serious adverse events, 6,258 deaths, and 78,488 never events were reported. There was an 84.4% increase in hospital participation in the Assessment of Practices, with most institutions classified as having medium or low compliance. There was a 26.5% increase in compliant criteria; however, on-site assessments did not reach 8% of hospitals. From 2021 to 2023, there was only a slight increase in hospital participation in the Culture Assessment. Of the 12 culture dimensions, only two were considered strengthened in 2023. In both editions, most participants rated PS as good or excellent, although three fragile dimensions persisted. Conclusions: Factors such as the persistence of underreporting and the low participation of hospitals with intensive care units (ICUs) in the National Assessments of Patient Safety Practices and the National Assessments of Patient Safety Culture may indicate a potentially more challenging scenario for the healthcare system.