Modelo para análise sistêmica de eventos graves de quedas, ações e aprendizado organizacional: estudo transversal

Abstract

Objective: To describe the analysis of severe adverse events related to inpatient falls and the planned actions in light of the London Protocol. Method: An observational, cross-sectional, descriptive study conducted with a non-probability sample of hospitalized patients who suffered severe falls between January 2020 and December 2024. Data collection was performed using fall notifications, electronic health records, and event analysis reports. Results: A total of 14 severe falls were identified during the period. Of these, nine occurred during the night shift (64.3%), nine involved male patients (64.3%), nine were in the 60 to 74 age group (64.3%), seven occurred among patients with incomplete primary education (50.0%), and eight took place in clinical specialty units (57.1%). Regarding the resulting harm, eight cases led to fractures (57.1%), five to traumatic brain injury (35.7%), and one to a laceration injury (7.1%). Of the 14 patients who suffered severe falls, six (42.9%) died as a result of the event. Conclusion: Based on the analysis of fall events, structural, educational, and managerial systemic actions were proposed to foster organizational learning.