The study aimed to identify the incident-adverse events reported in a surgical pediatric unit and characterize triggeringfactors. This is a retrospective field study, with a documentary and descriptive quantitative approach, developed atthe Pediatric Public Hospital in São Paulo, and data were collected for twelve months in 2015. 142 adverse eventsincidentswere identified related to skin lesions, loss of central venous catheter, loss of nasogastric, enteral andgastrostomy tube, fall, administration of medication, drainage loss, loss of epidural catheter and phlebitis, resulting inmild damage in infants.

The triggering factors were:

inadequate fixation of peripheral venous access, serum infiltration,use of inappropriate adhesive tape; leakage, disconnection, rupture or breakage of the central venous catheter;accidental removal of the tube, cracks; deflated balloon; medication not available, lack of attention or error, lack oftraining; recklessness; ineffective communication; divergence in the standard operating procedure and late materialreplenishment process. It was concluded that the nurse was the professional who stood out in the identification notificatório of the event, that the multiprofessional team and the patient-family should be encouraged to notify them,and that the detailed notifications generate preventive actions and strategies