ANALYSIS OF YOUTUBE VIDEOS ABOUT ADVERSE HEALTH EVENTS

This was an exploratory study with a quantitative approach carried out on the YouTube video sharing website. It aimed at analyzing videos from YouTube about adverse health events identifying the existence of relationships to patient safety. The search of videos was performed in December of 2013, on the YouTube website by combining “patient safety and adverse events”. Thirteen videos were analyzed according to the indicators: duration; author; date of posting; total views; category; approach; focus; health professionals cited; type of adverse health event approached; causes; consequences; prevention strategies; and relationships with patient safety. Despite the incipient number of videos being elucidated, considering the actual relevance of the subject, they highlighted the relationship between patient safety and adverse health event, focusing on prevention strategies.


INTRODUCTION
The advancement in research in the health care area has contributed to the improvement of care given to patients.However, even with this progress, people are still exposed to several risks, especially in the hospital environment. 1esearch show that the estimated number of deaths will increase due to several flaws during the hospitalization process.Among them, are: medication prescription errors, communication problems, failures in discharge-processes, errors during the surgical procedure.Such issues are health care consequences causing 44 to 98 thousand adverse events annually in US hospitals. 2n this context, the World Health Organization (WHO) began to worry about patient safety and set goals for preventing errors that may cause some injury.The patient safety concept is related to reducing the risk of unnecessary damage, associated with healthcare to an acceptable minimum. 2 Thus, expressing this world concern for patient safety and improving the quality of health services, the World Alliance for Patient Safety was created in 2004 by the WHO.
The Patient Safety Program, composed of several countries, seeks to define priority issues for research on the patient safety area that is highly relevant for countries at all levels of development.The most important among them are: healthcare for mothers and newborns; healthcare for the elderly; adverse events related to medication errors; fragile security culture focused on the process of responsibility for the error; skills and inadequate skills among health professionals; infections associated with health care. 3mong other guidelines, this alliance sought to organize the taxonomic aspects related to the patient safety subject by defining an incident as any event or circumstance which could have resulted, or resulted, in unnecessary damage to the patient.These events can be considered adverse events in health, being conceptualized as unintentional injuries resulting from health care, not related to the natural evolution of the underlying disease, which cause measurable injuries in affected patients and/or prolongation of hospitalization and/or death. 4herefore, it is important to support studies that seek to identify strategies for the prevention of adverse events related to healthcare.Meanwhile, the importance of the YouTube site is highlighted, which is today a worldwide information source, especially with regard to health problems.It is important, therefore, to pay attention to the fact that many of the videos posted on this site do not undergo any analytical treatment, not being of scientific nature, being therefore very important to pay attention to the quality of the material available on YouTube.
Nowadays, the Internet is an extremely important information area, which is unquestionably part of people´s everyday lives.TV shows, interviews, reviews, reports, home videos, everything can be seen and shared, anytime and anywhere. 5us, the expansion of interfaces through which users can interact and produce content is one of the characteristics associated with the called web 2.0,6 being relevant to consider the fact that any individual, for any purpose, can use sites like You-Tube to have access to different information,5 in particular related to health aspects.
Rated by Google as a content distribution platform, You-Tube provides opportunities to many users, to find, view, and share home or professionals videos. 7Therefore, it is a site that serves as a bank of audiovisual products, an online video service that allows users to upload them, share them, produce them, and publish them in digital format, being considered the most popular site of this type, and therefore, an unquestionable valuable tool for the contemporary society. 8he video language, with its synthetic nature creating a superposition of codes and meanings and predominantly audiovisual, has a significant power of illustration, 7 making the information ubiquitous and universal, with a range of potential without discrimination -literate and illiterate. 9ith such potential and unquestionable importance of videos available on the Internet in this contemporary time, it is imperative to pay attention to the quality of the material being used because when addressing issues related to healthcare, the information may result in erroneous actions and/or thoughts, even compromising patient safety regarding to adverse health events.
It is evident that YouTube videos can be a tool to help the population in the teaching-learning process if using it with careful planning, with goals to enjoy all its potencialities. 10Aware of such assertive, some scholars have tried to analyze YouTube videos related to health aspects. 5,9,11,12hen addressing adverse health events, it becomes even more important to analyze the videos on YouTube about the topic, as it captures the media impact that the problem has often been addressed in an appealing way and hardly enlightening about potential prevention strategies.
Thus, the answer to the following research questions is sought: what YouTube videos show about adverse health events?Do they bring up relationships with patient safety?

OBJECTIVE
The objective of this study was to analyze YouTube videos about adverse health events, identifying the existence of relationships to patient safety.

MATERIAL AND METHODS
This was an exploratory study with a quantitative approach, performed on the YouTube video sharing site, with a virtual address as: www.YouTube.com.The choice of YouTube l type of adverse health events addressed: to indicate the type of reported adverse event; l causes for adverse health events reported: if considering the causes of adverse health events, indicate which were cited; l consequences of adverse health events reported: if considering the consequences of adverse health events, indicate which were cited; l prevention strategies for adverse health events addressed: if presenting strategies for the prevention of adverse events in health, indicate which were cited; l existence of a relationship with patient safety: Does the video relate adverse health events to patient safety?If so, which one?
The analysis of the indicators occurred through descriptive statistics.The approval of the ethics committee was not required because the research did not directly involve human beings, but used public domain material.

RESULTS
The search for videos on YouTube by combining "patient safety and adverse events" showed 70 results, which filtered from the "type of result -video", totaled 40 videos.They were watched individually and analyzed based on inclusion and exclusion criteria, and indicators of data collection, resulting in a final sample of 13 videos, corresponding to 18.6% of the amount initially found.
The characterization of the research sample is shown in Table 1, where the indicators are described: duration, author, date of posting, category, approach, and focus.
Videos with intermediate length predominated: nine (69.2%) videos were four to 20 minutes long.The 13 videos together had an analyzed moving image time of 1 h 39 min 25 s, with an average of 7 min 63 s per video.The shortest video was 1 min 42 s long and depicted an advertising campaign about safe surgery, sponsored by the Anestesia Segura Company.The longest video was 17 min 42 s long and showed an interview with the Coordinator of the Sentinel Surveillance Services from the National Health Surveillance Agency (ANVISA) -Patrícia Fernanda Toledo -about the Sentinel Network, posted by TVNBR, the channel that disseminates the TV videos of the Federal Government.
Most of the videos were posted by agencies linked to public service -six (46.3%) highlighted TVNBR; two (15.4%) were previously cited; and the Patient Safety Proqualis -two (15.4%).This last one is a portal linked to the Institute of Communication and Scientific and Technologic Information (ICICT) from the Oswaldo Cruz Foundation entitled Collaborating Center for Quality of Care and Patient Safety (PROQUALIS), which aims to disseminate information about the quality of care and patient safety.was due to currently being the most widespread video sharing site among Internet users. 8he study followed a research protocol composed of the elements: research topic; guiding questions; objective; research strategy; selection of studies; critical evaluation of studies; and presentation of results.
The research was performed in the YouTube search site in December of 2013 through the combination of the controlled keyword "patient safety" -extracted from Health Sciences Keywords (DeCS) -with the uncontrolled keyword "adverse events".The filter "type of result" offered by the site was used, choosing only "videos" as results.
Initially, the keywords combination was typed in the search field in the site, and then the filter offered by YouTube was applied.The links for the resulting videos in this initial search was saved for further analysis to not compromise the sample selection because the site is characterized by a continuous addition of new content.After this step, the research was conducted by visiting the selected links, without a defined location, because there is no restriction of access to videos visited in different sites, as it is the case in some other search sites.Thus, it was possible to visit them at different times, for the observation and analysis of pre-selected videos in an organized way.
Thus, the videos were analyzed individually, establishing as inclusion criteria: videos with direct reference to adverse health events; in verbal language -Portuguese -or non-verbal.Videos that did not answer the research question and/or did not relate to the topic were excluded, as well as duplicate videos.
After the initial selection of videos according to the inclusion and exclusion criteria, the selected sample was analyzed according to the following study indicators, which were synthesized in a Microsoft Excel 2010 worksheet: l video approach: if theoretical, only with theoretical elements about adverse health events; practical, only with aspects related to care practices in adverse health events; or theoretical and practical, with both theoretical and practical elements; l focus: to classify according to the general objective of the video -to educate, disseminate news, promote new products, or other (specify); l health professionals cited: to report all professionals cited as involved in adverse healthcare events; The analyzed videos were recent, from the last three years, especially from 2013 -eight (53.8%).Adding the total number of views of all videos, there were 13,352 views, with an average of 1,027 views per video.An educational video posted by Proqualis Patient Safety stood out, which demonstrates the use of a surgical safety checklist, already viewed 8,745 times.
According to the categorization of videos followed by You-Tube, which is defined by the author responsible for the posting, a higher quantity of Science and Technology videos was found -five (38.4%) -and Educational -four (30.8% ), which was confirmed by the analysis of the videos' approaches with a predominance of educational videos -nine (69.2%).
Most of the approaches were theoretical -nine (69.2%).Those who followed a theoretical and practical approachfour (30.8%) -used simulations of practical aspects of healthcare, especially for the videos demonstrating the use of tools for patient safety in surgical procedures -three (23.0%).
Regarding the cited health professionals, videos about multidisciplinary health teams in charge of prevention of adverse health events predominated -11 (84.6%).
Unanimously, the videos showed adverse health events as predictable and preventable, highlighting the necessary surveillance and reporting of incidents as potential events as a way to prevent that such incidents turn into actual adverse events, which result in harm caused to patients.Figure 1 shows the adverse health events cited in the videos.
The fact that such situations can be prevented and avoided using appropriate surveillance before they cause damage and become adverse health events is highlighted.
Strategies to prevent adverse health events were generally observed in all analyzed videos, focusing on a larger view of patient safety, which overcomes the culture of punishment to promote the safety culture.Table 2 presents the prevention strategies cited in the videos.As for the most often addressed types of adverse health events, surgical incidents and medication errors were highlighted, topics that include the six goals of the World Alliance for Patient Safety that are also incorporated into strategic acting areas in the National Program for Patient Safety (PNSP) established in April 2012 by Ordinance 529.
Adverse health events related to surgical procedures are also highlighted in the literature.This is because the surgical center (SC) is recognized as one of the most favorable units for the occurrence of these events, due to the characteristics of its own work process, diversity of surgical and diagnostic procedures, and intense circulation of people from different professional categories. 17hus, it is estimated that more than half of occurring adverse health events are estimated at about 4-16% of all hospitalized patients are related to surgical care.14 Each year, out of the 234 million surgeries worldwide, two million deaths and seven million incidents are estimated to occur, 50% of them being avoidable.16 In view of these alarming data, safe surgery is established as one of the global goals related to patient safety.
Errors related to medication systems are also highlighted as one of the most common types of adverse events related to hospitalization, affecting a significant number of people and increasing the costs of health system significantly.18 They are also the most conveyed by the media, mainly related to the nursing profession that acts directly or indirectly in all phases in the medication system.
The videos highlighted the following among causes of adverse health events: lack of human resources; fatigue; poor professional qualification; incorrect care plans; and lack or bad communication between health professionals.The last one was highlighted as the root cause of adverse health events.
It is emphasized that effective communication, in an interdisciplinary way, favors a single language, translated into a safe health care, and avoiding inaccurate information, which may predispose to an adverse health event. 19A secure communication process must take place both among health professionals, and between them and patients, to avoid identification errors and failures arising from the neglect of important aspects of the care process that are not properly communicated.

DISCUSSION
Similar to other studies, 5,11 the 13 videos analyzed focused on educational aspects related to adverse health events, potentially revealed as useful for the protection of population health.
It was also possible to observe the significant reach of the studied videos, which altogether were seen 13,352 times.It was observed that the most watched videos showed an evaluation for future users 7 since YouTube organizes the sequence of videos from the most viewed and evaluated.Thus, the mostwatched and best-evaluated videos appear first in the search by users, and therefore, they should be carefully analyzed for quality of content, since they will be the primary source of information.In addition, these videos can represent training disseminators of knowledge about adverse health events.
The highlighted theoretical aspects addressed in the videos were: the concept; types; causes; consequences; and mechanisms for the prevention of adverse health events.
The videos addressed adverse health events as preventable incidents, although there is no standardization of concepts shown in each video, mostly informally reported, without reference to any specific definition.The lack of a standardized taxonomy to follow is cited in the literature as an aspect that hinders further analysis of the subject because in most cases each study follows a specific concept. 13herefore, seeking to standardize definitions for the main concepts in the literature about patient safety, the WHO, through the Patient Safety Program, developed the Patient Safety International Classification (ICPS) in which an incident is defined as any event or circumstance that could have resulted, or resulted, in unnecessary harm to the patient; incidents with damage correspond to adverse health events. 13,14[16]  training, joint surveillance, patient´s collaboration, communication, creation of Patient Safety Centers, notification, correct identification, hand hygiene, nursing process, use of surgical safety checklist, use of the 10 steps for safe anesthesia, more concern for professionals occupational health, risk management, time-out, management of high-risk medications, and use of the "sures" in the medication system The videos, unanimously in this study (13; 100%) as well as in the literature, highlighted an intrinsic relationship between patient safety and adverse health events, with a focus on prevention strategies, relating the continuous evaluation of health services to the quality and safety of the care process.
Thus, it was emphasized that the prevention of adverse health events must arise from a systemic view, exceeding the minimalist, individual, and punitive view of the problem.This systemic view is characterized by promoting patient safety culture, defined as the product of values, attitudes, skills, and individual and group behavior patterns, which determine the commitment, style, and proficiency of the administration of a healthy and safe organization. 3,4,16cholars cite the understanding of the multifactorial character under security failures based on the theory of human error proposed by James Reason, Professor of Psychology at the University of Manchester, UK, named Swiss Cheese Theory.It infers that the source of the problem would often be triggered by multiple factors: as if the occurrence of adverse events was due to the alignment of several "holes" that could be structural or occasional failures, malpractice or neglect from health professionals, and unsafe or risky behavior by the patients. 3s a main element in promoting patient safety culture, the videos highlighted the patient as a key element in the process of prevention of adverse events who must take part of the safety precautions that will be beneficial to self.It is noteworthy that the patient involvement is recommended to ensure self-safety, becoming the last barrier for the interception of an incident and an important evaluator of the safety and quality of care received. 16he videos also highlighted a challenge that is experienced in the promotion of patient safety as a means of preventing the occurrence of adverse health events: the responsibility of professionals, managers, and patients -the protagonists of the health work process -for changes in the insecurity scenario that features health environments today.

FINAL CONSIDER ATIONS
Despite the great impact of the topic of adverse health events, the existence of videos that disclose aspects of the promotion of patient safety in relation to the prevention of adverse events in the YouTube sharing site is currently still incipient.
The analyzed videos were produced and posted recently, despite that adverse health events have been a subject discussed worldwide for a long time.However, a strong impact on patient safety is observed in recent years in the Brazilian scenario, especially in 2013, when the Patient Safety National Policy was established.Therefore, it is observed that the technical quality of the videos is an essential aspect, not only of the quality of the im-In this sense, it is highlighted not only the spoken but also the writing language through records.Thus, the absence or inadequate documentation of information in the medical record can be related to the occurrence of adverse events, since it is from them that the necessary information for the specific and proper treatment of the patient is obtained. 20herefore, the communication must be made both as a protective element to prevent the occurrence of the adverse event before it happens and as a learning element through the error, after the occurrence of adverse health events and based on the notification, an aspect highlighted in the sampled videos analyzed in this study.
The relevance of notifying adverse health events is to promote the identification of these events, providing a practical means of communication about these unexpected and unwanted facts, enabling the exploration of situations, building a risk and situations-problem database, enabling the implementation of necessary or appropriate changes in the care process, and contributing to management for planning safer work processes, allowing the prevention of future adverse events. 15This process is synthesized in the videos as the "learning from errors" process.
However, it is emphasized in the literature that the phenomenon of underreporting adverse health events is still experienced mainly due to the non-incorporation of notification processes in routine work or professional insecurity due to the culture of punishment before an error that still exists in institutions, leading to the omission of facts and making it difficult for a realistic estimation of the problem. 15,16,18he analyzed videos also highlighted the consequences of adverse health events including: moral, physical, and/or psychological damages; high risk of complications; increase in the length of hospitalization; increase in care costs; disabilities; and death.The risk of law suits arising from the adverse events was also evidenced.
Studies show that the 1990s marked an increase in sensationalist approaches in the media about errors in health and growth of judicial disputes, both in number of cases as in financial value of damages.Health care has increasingly become a form of provision of services subjected to contract laws and their consequences in the civil and criminal areas. 18urrently, it is observed that the diagnosis of errors is recognized as a cause of more frequent and financially costly legal proceedings, occurring between 10 and 15% of all healthcare assistance. 16Thus, one video highlighted discussions on a compensation system for victims of adverse events, which already exists in some European countries -Sweden, Finland, Francewhere there is a compensation system in an arbitration framework within the institution, extra judicially.It was observed, therefore, that further studies are needed to assess how such systems may promote the culture of patient safety.age in motion, but the concepts and approaches shown.It was evident, therefore, a lack of standardization in the concepts worked in the videos, an aspect that may hinder further analyses in the topic.The user who seeks to be updated watching videos will need to make a careful analysis on the quality of the transmitted technical information.
Given that YouTube is the most widespread site among Internet users and many use it as a source of research, the importance of analyzing the quality and reliability of the information posted is emphasized.In addition, it is understood that the selection and appropriate production of videos can create appropriate opportunities for their use in spaces of training and educational classes, favoring the fixation of the above content.

l
duration: shown in the timeline of the video (in minutes and seconds -nn'nn"); l author: responsible for posting the video -if from an individual, agency, or company; l date of posting: indicated in the video description; l total number of views: indicated under the video; l category (according to YouTube classification): indicated in the video description;

Table 1 -
Characteristics of video components in the studied sample; 2013 Figure 1 -Adverse health events cited in the analyzed videos; 2013.Source: research data.

Table 2 -
Strategies to prevent adverse health events highlighted in the videos; 2013 Programs follow up/ formalized protocols for monitoring patient safety World Alliance for Patient Safety National Program of Patient Safety Bundle do Institute for Health care Improvement Required Organizational Practices recommended by hospital accreditation Use of tools to promote patient safety Proper organization, adoption of protocols, adequacy of human resources, teamwork, training and ongoing