Difficulties and strategies of Patient Safety Centers in reporting adverse events in hospitals           /              Dificuldades e estratégias dos Núcleos de Segurança do Paciente na notificação de eventos adversos hospitalares

Monica Maria de Melo  Andrade; Adane Domingues  Viana; Gisella  de Carvalho Queluci; Jackeline Franco Couto; Teresa Tonini

doi:10.9789/2175-5361.rpcfo.v17.13449

Authors

Monica Maria de Melo Andrade Federal University of the State of Rio de Janeiro https://orcid.org/0000-0002-1352-0254
Adane Domingues Viana Instituto Municipal de Vigilância Sanitária do Município do Rio de Janeiro https://orcid.org/0000-0001-9783-2716
Gisella de Carvalho Queluci Federal University of the State of Rio de Janeiro https://orcid.org/0000-0003-0496-8513
Jackeline Franco Couto Vigilância Sanitária do Estado do Rio de Janeiro https://orcid.org/0000-0002-7720-0102
Teresa Tonini Federal University of the State of Rio de Janeiro https://orcid.org/0000-0002-5253-2485

DOI:

https://doi.org/10.9789/2175-5361.rpcfo.v17.13449

Keywords:

Instalações de saúde; Hospitais; Assistência hospitalar; Gestão de riscos; Segurança do paciente; Indicadores de qualidade em assistência à saúde; Qualidade da assistência à saúde; Avaliação de processos e resultados em cuidados de saúde.

Abstract

Objetivo: identificar los desafíos y facilidades del Centro de Seguridad del Paciente en el manejo de Eventos Adversos. Método: revisión integrativa de la literatura de artículos publicados entre 2013 y 2023 con búsqueda realizada en marzo de 2023. Resultados: Se identifica la necesidad de comprender la importancia de la notificación de Eventos Adversos y la instrumentación de indicadores de calidad. A partir de la información recopilada es posible describir la situación y desarrollar estrategias para promover la seguridad del paciente. Destaca el aprendizaje de los errores, con la asunción de una postura no punitiva. Conclusiones: Se considera fundamental que los profesionales de la salud comprendan la importancia de la notificación con la participación de la dirección durante todo el proceso, ofreciendo el apoyo necesario en el desarrollo de estrategias para promover la seguridad del paciente. Es importante identificar las debilidades que enfrenta el Centro de Seguridad del Paciente, desconociendo el carácter punitivo de la notificación de Eventos

Adversos.DESCRIPTORES: Establecimientos de salud; hospitales; Asistencia hospitalaria; Gestión de riesgos; Seguridad del paciente; Indicadores de calidad en la atención de salud; Calidad de la atención de salud; Evaluación de procesos y resultados en salud.

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Author Biographies

Monica Maria de Melo Andrade, Federal University of the State of Rio de Janeiro

Graduated in NURSING from the University of Pernambuco (1996), with specialization in Occupational Nursing (2012), Professional Education in the Health Area: Nursing (2004), Family Health Program (2007), Urgency and Emergency (2014) and in Dermatological Nursing (2020). With professional experience in the area of: Family Health as a Nurse and Supervisor; General ICU as an assistance nurse and coordination. Currently working as a Nursing Supervisor at the Gaffrée and Guinle University Hospital in the city of Rio de Janeiro. Studying a Professional Master's Degree in the Postgraduate Course in Health and Technology in the Hospital Space (PPGSTEH).

Adane Domingues Viana , Instituto Municipal de Vigilância Sanitária do Município do Rio de Janeiro

Nurse. PhD from the Postgraduate Program in Nursing and Biosciences at UNIRIO (2018). Master's degree in Nursing from the Federal University of the State of Rio de Janeiro (2010). Active member and Specialist in Surgical Center, Anesthetic Recovery and Material and Sterilization Center by the Brazilian Association of Surgical Center Nurses (Sobecc Nacional, 2013). Specialist in Surgical Center, Material Center and Post-Anesthetic Recovery, from Estácio de Sá University (2014). Specialist in Professional Education in the Health Area from Fiocruz / UERJ (2005). Graduated in Nursing and Obstetrics, from the Alfredo Pinto School of Nursing - UNIRIO (1998). Currently, coordinates the operating room of the Souza Aguiar Municipal Hospital, in Rio de Janeiro. Nurse at the Emergency Room, SPA IIEngenhoca in Niterói. Coordination of the Rio de Janeiro Nucleus of the Brazilian Network of Nurses in Patient Safety (Rebraensp), 2020-2022 management. Experience in Nursing, perioperative nursing care, nursing management/administration, patient safety. (Text provided by the author).

Gisella de Carvalho Queluci, Federal University of the State of Rio de Janeiro

She is currently the Coordinator of the Postgraduate Program in Health and Technology in the Hospital Space - PPGSTEH / UNIRIO. Associate Professor in the Department of Fundamental Nursing at the Alfredo Pinto School of Nursing at the Federal University of the State of Rio de Janeiro (UNIRIO). Professor at the Fluminense Federal University from 2006 to 2019. PhD and Master's Degree in Nursing from EEAN / UFRJ. Post-Doctorate in Epistemology for Nursing from EEAN / UFRJ. Collaborating Professor of the Professional Master's Degree in Health Education - UFF (2011-2022). Permanent Professor of the Postgraduate Program in Health and Technologies in the Hospital Space / UNIRIO. Research Line: Pedagogical Training and Nursing Care, SAE, especially with the use of Active Methodologies in the teaching-learning process. Member of the Research Group: Professional Training and Qualification: Education and Health; Study Group on Systematization of Nursing Care - GESAE- UFF. (CNPq), member of the Center for Research and Experimentation in Fundamental Nursing - NUPEEF/UNIRIO. Training in Aromatherapy (PICs).

Jackeline Franco Couto, Vigilância Sanitária do Estado do Rio de Janeiro

Graduated in NURSING from the Federal University of the State of Rio de Janeiro (1995); Master in Education and Health Sciences from Plinio Leite University (2004). DOCTORATE from the Federal University of the State of Rio de Janeiro (2020). Nurse Inspector of the Regional Nursing Council-RJ (2011) and Nurse of the Patient Safety and Risk Management Coordination of the Superintendence of Health Surveillance of Rio de Janeiro (2016-2024). Nurse of the Office of the Superintendence of Health Surveillance-RJ. Judicial Expert by the Institute of Judicial and Criminal Expertise of Rio de Janeiro (2023). Coordinator of the Brazilian Nursing and Patient Safety Network (REBRAENSP) - Rio de Janeiro Nucleus (Management 2023-2025). She has experience in the area of Nursing, with an emphasis on Nursing in Infectious Diseases, Medical-Surgical, Health Education, working mainly on the following topics: Prevention and Control of Hospital Infection, Patient Safety, Inspection in Health Establishments and Long-Term Care Institutions for the Elderly.

Teresa Tonini, Federal University of the State of Rio de Janeiro

PhD in Public Health (2006) from the Institute of Social Medicine (IMS) of the State University of Rio de Janeiro (UERJ). Master's degree in Nursing (1999) and Bachelor's degree in Nursing and Obstetrics (1986) from the Anna Nery School of Nursing (EEAN) of the Federal University of Rio de Janeiro (UFRJ). Associate Professor of the Department of Fundamental Nursing; Coordinator of the Postgraduate Program in Nursing and Biosciences (PPGENFBIO) - Management 2013-2016; Coordinator of the Postgraduate Program in Nursing (PPGENF) - Management 2010-2013 and Coordinator of the Postgraduate Program in Health and Technology in the Hospital Space (PPGSTEH) - Management 2020-2021 of the Federal University of the State of Rio de Janeiro (UNIRIO). Institutional Representative in the International Network of Collaborating Centers of the Index Foundation. Member of the Academic Committee of the Doctoral College of Nursing of the Tordesillas Group from 2014-2022. Director of the Tordesillas Doctoral College of Nursing - Management 2023-2024. Coordinator of the interinstitutional agreement with the Universidad Sur Colombiana - USCO (Neiva/Colombia) and of the interinstitutional agreement with the State University of Roraima (UERR) from 2013 to 2017. International Advisor to USCO for the Implementation of the Doctoral Course in Health Sciences (2014-2018). Alternate Councilor of the Regional Nursing Council (COREN-RJ) - Management 2015-2017. Experience in the areas of Nursing and Public Health, with study objects on the following topics: nursing, nursing care, nursing management/administration, health assessment, assessment of nursing services, patient safety.

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