<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>1679-4974</journal-id>
<journal-title><![CDATA[Epidemiologia e Serviços de Saúde]]></journal-title>
<abbrev-journal-title><![CDATA[Epidemiol. Serv. Saúde]]></abbrev-journal-title>
<issn>1679-4974</issn>
<publisher>
<publisher-name><![CDATA[Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S1679-49742018000200010</article-id>
<article-id pub-id-type="doi">10.5123/s1679-49742018000200004</article-id>
<title-group>
<article-title xml:lang="pt"><![CDATA[Notificações de eventos adversos relacionados com a assistência à saúde que levaram a óbitos no Brasil, 2014-2016]]></article-title>
<article-title xml:lang="es"><![CDATA[Registros de eventos adversos relacionados con la asistencia de salud que resultaron en muertes en Brasil, 2014-2016]]></article-title>
<article-title xml:lang="en"><![CDATA[Registry of adverse events related to health care that results in deaths in Brazil, 2014-2016]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Maia]]></surname>
<given-names><![CDATA[Christiane Santiago]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Freitas]]></surname>
<given-names><![CDATA[Daniel Roberto Coradi de]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Gallo]]></surname>
<given-names><![CDATA[Luciana Guerra]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Araújo]]></surname>
<given-names><![CDATA[Wildo Navegantes de]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Agência Nacional de Vigilância Sanitária Diretoria de Coordenação e Articulação do Sistema Nacional de Vigilância Sanitária ]]></institution>
<addr-line><![CDATA[Brasília DF]]></addr-line>
<country>Brazil</country>
</aff>
<aff id="Af2">
<institution><![CDATA[,Universidade de Brasília Faculdade de Medicina ]]></institution>
<addr-line><![CDATA[Brasília DF]]></addr-line>
<country>Brazil</country>
</aff>
<aff id="Af3">
<institution><![CDATA[,Universidade de Brasília Faculdade de Ceilândia ]]></institution>
<addr-line><![CDATA[Brasília DF]]></addr-line>
<country>Brazil</country>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>06</month>
<year>2018</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>06</month>
<year>2018</year>
</pub-date>
<volume>27</volume>
<numero>2</numero>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://scielo.iec.gov.br/scielo.php?script=sci_arttext&amp;pid=S1679-49742018000200010&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.iec.gov.br/scielo.php?script=sci_abstract&amp;pid=S1679-49742018000200010&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.iec.gov.br/scielo.php?script=sci_pdf&amp;pid=S1679-49742018000200010&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo  Objetivo:  descrever os eventos adversos relacionados com a assistência à saúde resultantes em óbito.  Métodos:  estudo descritivo das notificações registradas no Sistema de Notificações para a Vigilância Sanitária (Notivisa) no Brasil, de junho/2014 a junho/2016; notificações registradas como &#8216;outros&#8217; em &#8216;tipo de incidente&#8217; foram reclassificadas.  Resultados:  foram registrados 417 óbitos, a maioria em adultos e idosos (85%), sem diferenças entre sexos; os estados de São Paulo (N=92), Paraná (N=75) e Minas Gerais (N=66) foram os maiores notificadores; os hospitais contribuíram com 97% dos registros, com concentração nos setores &#8216;terapia intensiva&#8217; e &#8216;internação&#8217;; houve investigação pela unidade notificadora em 5% das notificações; na reclassificação do tipo de incidente, recuperaram-se 52 registros; o tipo de incidente mais comum foi &#8216;falhas durante a assistência à saúde&#8217; (50%).  Conclusão:  notificações resultantes em óbito ocorreram principalmente em hospitais; foram identificadas falhas no registro e necessidade de investigação de grande proporção dos óbitos.]]></p></abstract>
<abstract abstract-type="short" xml:lang="es"><p><![CDATA[Resumen  Objetivo:  describir los eventos adversos relacionados con la asistencia sanitaria que resultaran en muerte.  Métodos:  estudio descriptivo de las notificaciones registradas en el Sistema de Notificaciones para la Vigilancia Sanitaria (Notivisa) en Brasil entre junio/2014-junio/2016; las notificaciones registradas como &#8216;otros&#8217; en la variable &#8216;tipo de incidente&#8217; fueron reclasificadas.  Resultados:  se registraron 417 casos, la mayoría en adultos y ancianos (85%), sin predominio de sexo; los estados de São Paulo (N=92), Paraná (N=75) y Minas Gerais (N=66) fueron los mayores notificantes; los hospitales contribuyeron con el 97% de los registros; la investigación por la unidad notificante se produjo en el 5% de los casos; en la reclasificación, se recuperaron 52 registros; el tipo de incidente más común fue &#8216;fallas durante la asistencia sanitaria&#8217; (50%).  Conclusión:  las notificaciones de eventos resultantes de la muerte son principalmente de hospitales; se identificaron fallas en el registro y necesidad de más investigación de las muertes.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[Abstract  Objective:  to describe the adverse events related to health care resulting in death.  Methods:  a descriptive study of reports recorded in the Brazilian Health Surveillance Notification System (Notivisa) in Brazil from Jun 2014 to Jun 2016; notifications recorded as 'other' in the 'incident type' were recoded.  Results:  417 cases were recorded, mostly in adults and the elderly (85%), with no sex differences; the states of São Paulo (N=92), Paraná (N=75) and Minas Gerais (N=66) were the main reporter; hospitals contributed to 97% of the records, principally in the intensive care and hospitalization sectors; the investigation by the notifying unit occurred in 5% of cases; in the recode of the type of incident, 52 records were recovered; the most common type of incident was 'failures during health care' (50%).  Conclusion:  notifications resulting in death occurred mainly in hospitals; were identified failure to register and need to investigate the large proportion of deaths.]]></p></abstract>
<kwd-group>
<kwd lng="pt"><![CDATA[Segurança do Paciente]]></kwd>
<kwd lng="pt"><![CDATA[Sistemas de Informação]]></kwd>
<kwd lng="pt"><![CDATA[Óbito]]></kwd>
<kwd lng="pt"><![CDATA[Serviços de Saúde]]></kwd>
<kwd lng="pt"><![CDATA[Epidemiologia Descritiva]]></kwd>
<kwd lng="es"><![CDATA[Seguridad del Paciente]]></kwd>
<kwd lng="es"><![CDATA[Sistemas de Información]]></kwd>
<kwd lng="es"><![CDATA[Muerte]]></kwd>
<kwd lng="es"><![CDATA[Servicios de Salud]]></kwd>
<kwd lng="es"><![CDATA[Epidemiología Descriptiva]]></kwd>
<kwd lng="en"><![CDATA[Patient Safety]]></kwd>
<kwd lng="en"><![CDATA[Information Systems]]></kwd>
<kwd lng="en"><![CDATA[Death]]></kwd>
<kwd lng="en"><![CDATA[Health Services]]></kwd>
<kwd lng="en"><![CDATA[Epidemiology, Descriptive]]></kwd>
</kwd-group>
</article-meta>
</front><back>
<ref-list>
<ref id="B1">
<label>1</label><nlm-citation citation-type="book">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Kohn LT]]></surname>
<given-names><![CDATA[Corrigan JM]]></given-names>
</name>
<name>
<surname><![CDATA[Donaldson MS]]></surname>
<given-names><![CDATA[editors]]></given-names>
</name>
</person-group>
<collab>Institute of Medicine (US). Committee on Quality of Health Care in America</collab>
<source><![CDATA[To err is human: building a safer health system]]></source>
<year>2000</year>
<publisher-loc><![CDATA[Washington (DC) ]]></publisher-loc>
<publisher-name><![CDATA[National Academies Press (US)]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B2">
<label>2</label><nlm-citation citation-type="book">
<collab>Department of Health (UK)</collab>
<source><![CDATA[An organization with a memory: report of an expert group on learning from adverse events in the NHS]]></source>
<year>2000</year>
<publisher-loc><![CDATA[London ]]></publisher-loc>
<publisher-name><![CDATA[The Stationery Office]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B3">
<label>3</label><nlm-citation citation-type="book">
<collab>Ministério da Saúde (BR), Fundação Oswaldo Cruz, Agência Nacional de Vigilância Sanitária</collab>
<source><![CDATA[Documento de referência para o Programa Nacional de Segurança do Paciente]]></source>
<year>2014</year>
<publisher-loc><![CDATA[Brasília ]]></publisher-loc>
<publisher-name><![CDATA[Ministério da Saúde]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B4">
<label>4</label><nlm-citation citation-type="journal">
<collab>Brasil. Ministério da Saúde</collab>
<article-title xml:lang=""><![CDATA[Portaria MS/GM nº 529, de 1 de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP)]]></article-title>
<source><![CDATA[Diário Oficial da República Federativa do Brasil]]></source>
<year>2013</year>
<page-range>43</page-range><publisher-loc><![CDATA[Brasília (DF) ]]></publisher-loc>
</nlm-citation>
</ref>
<ref id="B5">
<label>5</label><nlm-citation citation-type="journal">
<collab>Brasil. Agência Nacional de Vigilância Sanitária</collab>
<article-title xml:lang=""><![CDATA[Resolução RDC nº 36, de 25 de julho de 2013. Institui ações para a segurança do paciente em serviços de saúde e dá outras providências]]></article-title>
<source><![CDATA[Diário Oficial da República Federativa do Brasil]]></source>
<year>2013</year>
<page-range>32</page-range><publisher-loc><![CDATA[Brasília (DF) ]]></publisher-loc>
</nlm-citation>
</ref>
<ref id="B6">
<label>6</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Ruciman]]></surname>
<given-names><![CDATA[W]]></given-names>
</name>
<name>
<surname><![CDATA[Hibbert]]></surname>
<given-names><![CDATA[P]]></given-names>
</name>
<name>
<surname><![CDATA[Thomson]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[van der Schaaf]]></surname>
<given-names><![CDATA[T]]></given-names>
</name>
<name>
<surname><![CDATA[Sherman]]></surname>
<given-names><![CDATA[H]]></given-names>
</name>
<name>
<surname><![CDATA[Lewalle]]></surname>
<given-names><![CDATA[P]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Towards an International Classification for Patient Safety: key concepts and terms]]></article-title>
<source><![CDATA[Int J Qual Health Care]]></source>
<year>2009</year>
<volume>21</volume>
<numero>1</numero>
<issue>1</issue>
<page-range>18-26</page-range></nlm-citation>
</ref>
<ref id="B7">
<label>7</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Jha]]></surname>
<given-names><![CDATA[AK]]></given-names>
</name>
<name>
<surname><![CDATA[Larizgoitia]]></surname>
<given-names><![CDATA[I]]></given-names>
</name>
<name>
<surname><![CDATA[Audera-Lopez]]></surname>
<given-names><![CDATA[C]]></given-names>
</name>
<name>
<surname><![CDATA[Prasopa-Plaizier]]></surname>
<given-names><![CDATA[N]]></given-names>
</name>
<name>
<surname><![CDATA[Waters]]></surname>
<given-names><![CDATA[H]]></given-names>
</name>
<name>
<surname><![CDATA[Bates]]></surname>
<given-names><![CDATA[DW]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[The global burden of unsafe medical care: analytic modelling of observational studies]]></article-title>
<source><![CDATA[BMJ Qual Saf]]></source>
<year>2013</year>
<volume>22</volume>
<numero>10</numero>
<issue>10</issue>
<page-range>809-15</page-range></nlm-citation>
</ref>
<ref id="B8">
<label>8</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Baker]]></surname>
<given-names><![CDATA[GR]]></given-names>
</name>
<name>
<surname><![CDATA[Norton]]></surname>
<given-names><![CDATA[PG]]></given-names>
</name>
<name>
<surname><![CDATA[Flintoft]]></surname>
<given-names><![CDATA[V]]></given-names>
</name>
<name>
<surname><![CDATA[Blais]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[Brown]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
<name>
<surname><![CDATA[Cox]]></surname>
<given-names><![CDATA[J]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[The Canadian adverse events study: the incidence of adverse events among hospital patientes in Canada]]></article-title>
<source><![CDATA[CMAJ]]></source>
<year>2004</year>
<volume>170</volume>
<numero>11</numero>
<issue>11</issue>
<page-range>1678-86</page-range></nlm-citation>
</ref>
<ref id="B9">
<label>9</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Zegers]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
<name>
<surname><![CDATA[Brujine]]></surname>
<given-names><![CDATA[MC]]></given-names>
</name>
<name>
<surname><![CDATA[Wagner]]></surname>
<given-names><![CDATA[C]]></given-names>
</name>
<name>
<surname><![CDATA[Hoonhout]]></surname>
<given-names><![CDATA[LH]]></given-names>
</name>
<name>
<surname><![CDATA[Waaijman]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[Smits]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Adverse events and potencially preventable deaths in Dutch hospitals: results of a retrospective patient record review study]]></article-title>
<source><![CDATA[Qual Saf Health Care]]></source>
<year>2009</year>
<volume>18</volume>
<numero>4</numero>
<issue>4</issue>
<page-range>297-302</page-range></nlm-citation>
</ref>
<ref id="B10">
<label>10</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Martins]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
<name>
<surname><![CDATA[Travassos]]></surname>
<given-names><![CDATA[C]]></given-names>
</name>
<name>
<surname><![CDATA[Mendes]]></surname>
<given-names><![CDATA[W]]></given-names>
</name>
<name>
<surname><![CDATA[Pavão]]></surname>
<given-names><![CDATA[AL]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Hospital deaths and adverse events in Brazil]]></article-title>
<source><![CDATA[BMC Health Serv Res]]></source>
<year>2011</year>
<volume>11</volume>
<page-range>223</page-range></nlm-citation>
</ref>
<ref id="B11">
<label>11</label><nlm-citation citation-type="book">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Daibert]]></surname>
<given-names><![CDATA[PB]]></given-names>
</name>
</person-group>
<source><![CDATA[Impacto econômico e assistencial das complicações relacionadas à internação hospitalar]]></source>
<year>2015</year>
<publisher-loc><![CDATA[Belo Horizonte, MG ]]></publisher-loc>
<publisher-name><![CDATA[Universidade Federal de Minas Gerais]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B12">
<label>12</label><nlm-citation citation-type="">
<collab>Brasil. Agência Nacional de Vigilância Sanitária</collab>
<source><![CDATA[Nota Técnica GVIMS/GGTES/ANVISA nº 01/2015. Orientações gerais para a notificação de eventos adversos relacionados à assistência à saúde]]></source>
<year>2015</year>
<publisher-loc><![CDATA[Brasília ]]></publisher-loc>
</nlm-citation>
</ref>
<ref id="B13">
<label>13</label><nlm-citation citation-type="book">
<collab>World Health Organization</collab>
<source><![CDATA[Conceptual framework for the international classification for patient safety: final technical report]]></source>
<year>2009</year>
<publisher-loc><![CDATA[Genebra ]]></publisher-loc>
<publisher-name><![CDATA[World Health Organization]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B14">
<label>14</label><nlm-citation citation-type="book">
<collab>NIHR Patient Safety Translational Research Centre at Imperial College London and Imperial College Healthcare NHS Trust (UK)</collab>
<source><![CDATA[National reporting and learning system research and development]]></source>
<year>2016</year>
<publisher-loc><![CDATA[London ]]></publisher-loc>
<publisher-name><![CDATA[Imperial College]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B15">
<label>15</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Lanzillotti]]></surname>
<given-names><![CDATA[LS]]></given-names>
</name>
<name>
<surname><![CDATA[Andrade]]></surname>
<given-names><![CDATA[CLT]]></given-names>
</name>
<name>
<surname><![CDATA[Mendes]]></surname>
<given-names><![CDATA[W]]></given-names>
</name>
<name>
<surname><![CDATA[Seta]]></surname>
<given-names><![CDATA[MH]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Eventos adversos e incidentes sem dano em recém-nascidos notificados no Brasil, nos anos 2007 a 2013]]></article-title>
<source><![CDATA[Cad Saúde Pública]]></source>
<year>2016</year>
<volume>32</volume>
<numero>9</numero>
<issue>9</issue>
<page-range>1-13</page-range></nlm-citation>
</ref>
<ref id="B16">
<label>16</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Coronado-Vázquez]]></surname>
<given-names><![CDATA[V]]></given-names>
</name>
<name>
<surname><![CDATA[García-López]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
<name>
<surname><![CDATA[López-Sauras]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
<name>
<surname><![CDATA[Turón Alcaine]]></surname>
<given-names><![CDATA[JM]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Nursing involvement in risk and patient safety management in primary care]]></article-title>
<source><![CDATA[Enferm Clín]]></source>
<year>2017</year>
<volume>27</volume>
<numero>4</numero>
<issue>4</issue>
<page-range>246-50</page-range></nlm-citation>
</ref>
<ref id="B17">
<label>17</label><nlm-citation citation-type="book">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Franzon]]></surname>
<given-names><![CDATA[JC]]></given-names>
</name>
</person-group>
<source><![CDATA[Notificação de incidentes e/ou eventos adversos em pediatria: estratégia para segurança do pacientes]]></source>
<year>2016</year>
<publisher-loc><![CDATA[Florianópolis, SC ]]></publisher-loc>
<publisher-name><![CDATA[Universidade Federal de Santa Catarina]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B18">
<label>18</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[McDonald]]></surname>
<given-names><![CDATA[TB]]></given-names>
</name>
<name>
<surname><![CDATA[Helmchen]]></surname>
<given-names><![CDATA[LA]]></given-names>
</name>
<name>
<surname><![CDATA[Smith]]></surname>
<given-names><![CDATA[KM]]></given-names>
</name>
<name>
<surname><![CDATA[Centomani]]></surname>
<given-names><![CDATA[N]]></given-names>
</name>
<name>
<surname><![CDATA[Gunderson]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
<name>
<surname><![CDATA[Mayer]]></surname>
<given-names><![CDATA[D]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Responding to patient safety incidents: the &#8220;seven pillars&#8221;]]></article-title>
<source><![CDATA[Qual Saf Health Care]]></source>
<year>2009</year>
<volume>19</volume>
<numero>6</numero>
<issue>6</issue>
</nlm-citation>
</ref>
<ref id="B19">
<label>19</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Vincent]]></surname>
<given-names><![CDATA[C]]></given-names>
</name>
<name>
<surname><![CDATA[Neale]]></surname>
<given-names><![CDATA[G]]></given-names>
</name>
<name>
<surname><![CDATA[Woloshynowych]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Adverse events in British hospitals: preliminary retrospective record review]]></article-title>
<source><![CDATA[BMJ]]></source>
<year>2001</year>
<volume>322</volume>
<page-range>517-9</page-range></nlm-citation>
</ref>
<ref id="B20">
<label>20</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Brennan]]></surname>
<given-names><![CDATA[TA]]></given-names>
</name>
<name>
<surname><![CDATA[Leape]]></surname>
<given-names><![CDATA[LL]]></given-names>
</name>
<name>
<surname><![CDATA[Laird]]></surname>
<given-names><![CDATA[NM]]></given-names>
</name>
<name>
<surname><![CDATA[Hebert]]></surname>
<given-names><![CDATA[L]]></given-names>
</name>
<name>
<surname><![CDATA[Localio]]></surname>
<given-names><![CDATA[AR]]></given-names>
</name>
<name>
<surname><![CDATA[Lawthers]]></surname>
<given-names><![CDATA[AG]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I]]></article-title>
<source><![CDATA[N Engl J Med]]></source>
<year>1991</year>
<volume>324</volume>
<numero>6</numero>
<issue>6</issue>
<page-range>370-6</page-range></nlm-citation>
</ref>
<ref id="B21">
<label>21</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Vries]]></surname>
<given-names><![CDATA[EN]]></given-names>
</name>
<name>
<surname><![CDATA[Ramrattan]]></surname>
<given-names><![CDATA[MA]]></given-names>
</name>
<name>
<surname><![CDATA[Smorenburg]]></surname>
<given-names><![CDATA[SM]]></given-names>
</name>
<name>
<surname><![CDATA[Gouma]]></surname>
<given-names><![CDATA[DJ]]></given-names>
</name>
<name>
<surname><![CDATA[Boermeester]]></surname>
<given-names><![CDATA[MA]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[The incidence ad nature of in-hospital adverse events: a systematic review]]></article-title>
<source><![CDATA[Qual Saf Health Care]]></source>
<year>2008</year>
<volume>17</volume>
<numero>3</numero>
<issue>3</issue>
<page-range>216-23</page-range></nlm-citation>
</ref>
<ref id="B22">
<label>22</label><nlm-citation citation-type="book">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Couto]]></surname>
<given-names><![CDATA[RC]]></given-names>
</name>
<name>
<surname><![CDATA[Pedrosa]]></surname>
<given-names><![CDATA[TMG]]></given-names>
</name>
<name>
<surname><![CDATA[Rosa]]></surname>
<given-names><![CDATA[MB]]></given-names>
</name>
</person-group>
<source><![CDATA[Erros acontecem: a força da transparência para o enfrentamento dos eventos adversos assistenciais em pacientes hospitalizados]]></source>
<year>2016</year>
<publisher-loc><![CDATA[Belo Horizonte ]]></publisher-loc>
<publisher-name><![CDATA[Instituto de Estudos de Saúde Suplementar]]></publisher-name>
</nlm-citation>
</ref>
<ref id="B23">
<label>23</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Rothschild]]></surname>
<given-names><![CDATA[JM]]></given-names>
</name>
<name>
<surname><![CDATA[Landrigan]]></surname>
<given-names><![CDATA[CP]]></given-names>
</name>
<name>
<surname><![CDATA[Cronin]]></surname>
<given-names><![CDATA[JW]]></given-names>
</name>
<name>
<surname><![CDATA[Kaushal]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[Lockley]]></surname>
<given-names><![CDATA[SW]]></given-names>
</name>
<name>
<surname><![CDATA[Burdick]]></surname>
<given-names><![CDATA[E]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care]]></article-title>
<source><![CDATA[Crit Care Med]]></source>
<year>2005</year>
<volume>33</volume>
<numero>8</numero>
<issue>8</issue>
<page-range>1694-700</page-range></nlm-citation>
</ref>
<ref id="B24">
<label>24</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Howell]]></surname>
<given-names><![CDATA[AM]]></given-names>
</name>
<name>
<surname><![CDATA[Burns]]></surname>
<given-names><![CDATA[EM]]></given-names>
</name>
<name>
<surname><![CDATA[Hull]]></surname>
<given-names><![CDATA[L]]></given-names>
</name>
<name>
<surname><![CDATA[Mayer]]></surname>
<given-names><![CDATA[E]]></given-names>
</name>
<name>
<surname><![CDATA[Sevdalis]]></surname>
<given-names><![CDATA[N]]></given-names>
</name>
<name>
<surname><![CDATA[Darzi1]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process]]></article-title>
<source><![CDATA[BMJ Qual Saf]]></source>
<year>2017</year>
<volume>26</volume>
<numero>2</numero>
<issue>2</issue>
<page-range>150-63</page-range></nlm-citation>
</ref>
</ref-list>
</back>
</article>
