Objective: Understanding the practice of reporting adverse events by health professionals. Method: A qualitative case study carried out in a teaching hospital with participants of the Patient Safety Center and the nursing team. The collection took place from May to December 2015, and was conducted through interviews, observation and documentary research to treat the data using Content Analysis. Results: 31 professionals participated in the study. Three categories were elaborated: The practice of reporting adverse events; Barriers in the effective practice of notifications; The importance of reporting adverse events. Conclusion: Notification was permeated by gaps in knowledge, fear of punishment and informal communication, generating underreporting. It is necessary to improve the interaction between leaders and professionals, with an emphasis on communication and educational practice.
Changes in nursing practice to improve patient safety ABSTRACTObjective: To identify changes in nursing practice to improve the quality of care and patient safety. Method: A case study conducted at an inpatient unit with professionals from the patient safety centre and a nursing team, totalling 31 participants. Data were collected from May to December 2015 through interviews, observations recorded in a field journal, and documentary analysis, followed by content analysis. Results:The changes observed in the nursing practice included the identification of care and physical risks, especially the risk of falls and pressure injury, with the use of personal forms and the Braden scale; notification of adverse events; adoption of protocols; effective communication with permanent education and multiprofessional meetings. Conclusions:Changes were observed in the nursing practice, chiefly focused on risk management. Resultados: Evidenciaram-se mudanças na prática de enfermagem como a identificação de riscos assistenciais e físicos; destaque para risco de queda, lesão por pressão, com adoção de impressos próprios e uso da escala de Braden; notificação de eventos adversos; identificação do paciente; adoção de protocolos; comunicação eficaz com educação permanente e reuniões de forma multiprofissional. Conclusões:Ocorreram mudanças na prática de enfermagem, principalmente voltadas para o gerenciamento dos riscos. Palavras-chave: Segurança do paciente. Enfermagem. Assistência à saúde. RESUMEN Objetivo: Identificar los cambios en la práctica de enfermería para mejorar la calidad de la atención y la seguridad del paciente. Método: Estudio de caso en una unidad de hospitalización con profesionales del Centro de Seguridad del Paciente y el personal de enfermería; 31 participantes. Entre mayo y diciembre de 2015 se llevaron a cabo entrevistas, observación de campo y análisis diario documento, sometido a análisis de contenido.Resultados: Se evidenciaron cambios en la práctica de enfermería como la identificación de riesgos de asistencia y físicos; destaque para riesgos de caída lesión por presión, con la adopción de formas y uso de la escala de Braden específicos; la presentación de informes de eventos adversos; la identificación del paciente; adopción de protocolos; comunicación efectiva con educación permanente y reuniones de fiorma multidisciplinaria. Conclusiones:Los cambios ocurridos en la práctica de enfermería, se centraron principalmente en la gestión de riesgos. Palabras clave: Seguridad del paciente. Enfermería. Atención a la salud.Siman AG, Brito MJM 2 Rev Gaúcha Enferm. 2016;37(spe):e68271
Objective: to understand the professional practice challenges in reaching the goals and objectives of the National Patient Safety Program (Programa Nacional de Segurança do Paciente). Method: qualitative case study, based on the Comprehensive Sociology, carried out with 31 professionals from the Patient Safety Center (Núcleo de Segurança do Paciente) and the nursing team, working in a teaching hospital. Data collection took place between May and December 2015 through interviews, observation and documentary analysis. The analysis proceeded according to the prerogatives of the Content Analysis. Results: three categories emerged: the prescribed reality; material resources and their impact on care; and human resources related to the reality. Final considerations: challenges to safe professional practice are caused by inadequate physical structure, insufficient physical and human resources, but mainly invade the transition from the prescriptive reality scope.
The difficulties encountered when using these indicators revealed the following constituent elements: lack of time, inadequate number of professionals and lack of knowledge on the subject. It was concluded that nurses understand that indicators are instruments that enable evaluations and improvements, but their understanding of how to use these instruments is incomplete and fragmented.
Objetivo: compreender a dimensão prescrita e real das práticas de profissionais de saúde no contexto da segurança do paciente. Método: estudo de caso qualitativo. Os participantes foram 31 profissionais: membros do Núcleo de Segurança do Paciente e a equipe de enfermagem de um hospital de ensino, localizado em Minas Gerais, Brasil. Os dados foram coletados por meio de entrevistas com roteiro semiestruturado, observação e dados secundários. Foi realizada triangulação de dados e a análise de conteúdo. O projeto foi aprovado no Comitê de Ética em Pesquisa, CAAE 44109015.0.0000.5149. Resultados: as transformações ocorridas, como a criação do núcleo, plano de segurança do paciente e protocolos, foram evidenciadas mais na concepção prescritiva. A segurança do paciente não foi priorizada como diretriz estratégica do hospital. Falta capacitação da equipe e avaliação das ações. Conclusão: a segurança do paciente foi evidenciada mais no âmbito prescrito. O trabalho realizado não corresponde exatamente àquele proposto pelas regras e protocolos.
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