Never events relacionados ao suicídio ou danos auto infligidos durante a assistência à saúde no Brasil

Abstract

Patient safety is understood as the reduction of unnecessary risks associated with healthcare services to an acceptable minimum. The National Patient Safety Program (NPSP), developed by the National Health Surveillance Agency (ANVISA), recommends measures to reduce incidents related to healthcare services, including the establishment of Patient Safety Units (PSUs). Among the adverse events resulting from the provision of care, there are "never events," which are events that should never occur in healthcare services. Among these, the "patient suicide, suicide attempt, or self-inflicted harm resulting in serious injury during healthcare service" is reported. This is a mental health-related problem that has gained considerable worldwide attention. Therefore, this study aims to describe the profile of never events related to "patient suicide, suicide attempt, or self-inflicted harm resulting in serious injury during healthcare service" in Brazil. Method: A quantitative and descriptive documentary study based on research with data from incident notification reports published between 2018 and 2022. The data collected variables included the number of these never events distributed by year, region, and states of the federation. The data were analyzed using simple descriptive statistics. Results and discussion: Between 2018 and 2022, a total of 346 never events related to "patient suicide, suicide attempt, or self-inflicted harm resulting in serious injury during healthcare service" were reported, with an increasing distribution during the period, with 2022 standing out with 117 cases (33.8%). Among the country's regions, the Southeast had the highest number of notifications, responsible for 158 of the cases reported in the country between 2018 and 2022, respectively. Regarding the state with the highest number of notifications during the period, Minas Gerais stands out, reporting 124 cases (35.8%) in the country. Conclusion: It is essential for healthcare professionals to recognize the risk signs for these never events during patient care to prioritize their detection and develop actions to prevent their recurrence. Properly referring patients for appropriate follow-up is also crucial. Underreporting of these events should be considered, and the establishment of Patient Safety Units (PSUs) in healthcare services should be encouraged for prevention and accurate reporting of such cases.