Never Event relacionado a óbito intraoperatório ou imediatamente pós-operatório no Brasil: estudo descritivo

Abstract

Objective: To describe the reporting profile of never events related to intraoperative or immediate postoperative/post-procedure death in ASA Class 1 patients in Brazil from 2019 to 2023. Method: This is a descriptive and documental study conducted through a review of adverse event reporting records from all Brazilian states. Data analysis was performed using simple descriptive statistics. Results: The reporting profile of never events related to intraoperative or immediate postoperative deaths showed a growing trend over the years, totaling 150 notifications to ANVISA, with 2023 standing out as the year with the highest number of reports, predominantly from the Southeast region. The state of São Paulo accounted for the majority of notifications. In contrast, the North and Northeast regions presented the lowest absolute and relative frequencies, with some states reporting no occurrences of the analyzed never event compared to other regions. Conclusion: Never events related to intraoperative or immediate postoperative/post-procedure deaths in ASA Class 1 patients in Brazil demonstrate an increasing number of notifications. This trend may reflect improved reporting quality by Patient Safety Centers, established under Ministry of Health (MS) Ordinance No. 529/2013 and the National Health Surveillance Agency (ANVISA), which aim to prevent and reduce incidents in healthcare services that could harm patients, alongside greater awareness of the importance of reporting.