Eventos adversos e segurança na assistência de enfermagem

Abstract

Objective: to identify the scientifi c publications about adverse events in nursing care in adult hospitalized patients and discuss the main adverse events in nursing care. Method: Integrative revision with a qualitative approach. The data were collected at LILACS, MEDLINE, BDENF and the library SCIELO and were submitted to thematic analysis. Results: three categories were developed: Adverse events in nursing care; The main causes of the adverse events in nursing care; Attitude of nursing professionals in face of errors. The main events were identifi ed in nursing care with emphasis on the medication error, the failure to perform dressings and falls of patients. The importance of instruments was emphasized for notifi cation of adverse events in the institutions. However the fear of punishment on professionals stimulates the underreporting of events. Conclusion: it is important to discuss effective prevention strategies that ensure patient safety in healthcare institutions.

The practice of reporting adverse events in a teaching hospital

“…This is why a permanent education program and the encouragement of adherence to protocol and guidelines are vital aspects that should be part of the priorities list of NSP members, hospital managers and health professionals involved in care (24) . Nevertheless, professionals' fear of punishment found in the results may encourage underreporting (18) . The fact that it is a hospital that participates in the Sentinel Hospitals Network reinforces the need to stimulate the notifications.…”

“…A previous study identified the practice of informal communication and the omission of adverse events among professionals in hospital practice (17) . The perception and conduct of professionals in relation to errors may vary according to the institutional culture (punitive or not) (18) , and is also closely related to individual responsibility (19)(20) . Thus, it is important to invest in disseminating safety culture with an emphasis on education and communication, adopting conducts based on protocols, guidelines and SOPs, expanding safety knowledge according to the perspective of continuous construction, taking into account the reality of the institution and also the meanings and values that the professionals attribute to patient safety.…”

“…The lack of knowledge or lack of understanding of the team that any professional is able to commit mistakes can lead to feelings of shame, guilt and fear, which can be aggravated by the punitive culture predominant at the institution under study, contributing to hiding the episodes (18,20) . This is why a permanent education program and the encouragement of adherence to protocol and guidelines are vital aspects that should be part of the priorities list of NSP members, hospital managers and health professionals involved in care (24) .…”

“…It is necessary for the managers of the institution to understand that AEs are often directly related to failures in the system and work processes, not to the individual due to professional negligence or incompetence. Instead of looking for culprits, weaknesses in the process should be identified along with adoption of preventive measures, thus improving notifications, and consequently learning from the mistakes (18,20,24) . It is worth emphasizing that risk is a constant reality in health organizations.…”

Cultura De Segurança Do Paciente: Avaliação Pelos Profissionais De Enfermagem

“…In addition, these facts add to the need to understand about adverse events by the professionals involved and the adoption of a non-punitive culture when faced with the event installed. [22][23] From the perspective that the professional participation is fundamental to the development of quality care, their preparation is directly associated with the improvement of systems and the care process, which should be focused on teamwork, patient-centered care, in evidence-based practices, in the use of information technology and in improving quality. 24 The valuation of patient safety and the implementation of measures for this purpose should be a priority for all professionals, especially those in positions at the top of the organization chart so that the positive results are evidenced in the work processes in the field of patient safety.…”