Bohomol and Ramos2828 Bohomol E, Ramos LH. Erro de medicação: importância da notificação no gerenciamento da segurança do paciente. Rev. Bras. Enferm. 2007; 60(2):32-36.
(2007) |
Quantitative
descriptive |
To verify with the nursing team their understanding of what a medication error is and express their opinion regarding the notification of the event and the completion of the report of medication adverse events. |
- 70.1% of practitioners reported that some medication errors are not reported because the staff member fears the reaction they will suffer from the responsible nurses or co-workers.
- 21.8% reported that they non-notified the medication error because they felt the error was not serious enough to justify reporting.
- There was no uniform understanding as to what a medication error is, when it should be informed to the doctor and filled an events reporting. |
"There is a need to develop educational programs that elucidate what medication errors are, discussing settings to understand the causes of the problem with proposed improvements."
"The health services administration should be focused on developing a work system to reduce or eliminate barriers to reporting medication errors, focusing on patient safety as a high quality health care standard." |
Coli et al.2323 Coli RCP, Anjos MF, Pereira LL. Postura dos enfermeiros de uma unidade de terapia intensiva frente ao erro : uma abordagem à luz dos referenciais bioéticos. Rev. Latino-Am.Enfermagem 2010; 18(3):324-30.
(2010) |
Qualitative |
To analyze the attitude of nurses in the face of errors that occur in nursing procedures in an ICU in the light of bioethics. |
- Stance of recognizing errors, a recognition that, even involuntarily, one might commit errors and the importance of communicate errors.
- Omission errors happen, showing that they are not always reported. Error omission occurs when professionals know that it will not bring immediate consequences to the patient, because the expectation of non-failure is in force and when the error involves more people or teams. |
"Rethinking nursing practice based on bioethics, resorting to an error analysis also focused on the relationships between those involved. Keeping in mind that errors occurs in a network of relationships, thus, should not be seen individually or only in technical terms, but rather in a relational way, and seek an integrated understanding of reality." |
Claro et al.2929 Claro CM, Krocockz DVC, Toffolleto MC, Padilha KG. Eventos adversos em Unidade de Terapia Intensiva- percepção dos enfermeiros sobre a cultura não punitiva. Rev Esc Enferm USP. 2011; 45(1):167-172.
(2011) |
Quantitative
descriptive |
To characterize the AE record at the ICUs; verify AE frequency and the existence of punishment according to the nurses' perception; identify the nurses' degree of safety to notify AE. |
- 71.4% mentioned sub-notification (underreporting) of AE.
- Professionals indicated 115 reasons for underreporting. Main reasons: work overload (25.2%); forgetfulness (22.6%); non-valuation of AE (20.0%); feelings of fear (15.7%).
- 74.3% mentioned that punishment sometimes or always occurs.
- 83.7% indicated that the nurses were responsible for the notification.
- 21.4% of nurses showed hardly safe or unsafe to report AE in their institution. |
The results and limitations of the study point to "the need for further research and discussion on the theme."
"Professionals need to overcome the punishment culture and AE registration systems need to be put in practice to improve care quality and, consequently, to achieve ICU patient safety."
"Need for educative programs on patient safety directed to intensive care professionals and hospital institutions in general." |
Silva et al.3030 Silva RCL, Cunha JJS, Moreira CLS. Adverse events in intensive care: what they know the nurses. Revista de Pesquisa: Cuidado é Fundamental. 2011; 3(2):1848-1855.
(2011) |
Quantitative
descriptive |
Identify the level of knowledge of nursing professionals about what it is, how it is identified and how to report an AE. |
- 21% of professionals said they could not identify an AE.
- 51% of professionals said they were unaware of the existence of a risk management sector in the service they work for.
- At least 36% of AEs experienced by the professionals were not reported by them.
- 14% of participants heard about AE during vocational training, in a context where 41% of participants had less than a year's graduation.
- The authors considered the following factors favoring low reporting: lack of knowledge about what it is, how it is identified and how an AE is reported; leaving the reporting under the responsibility of the nurse and for not having sufficient knowledge to report. |
"The health institution must promote a non-punishment culture, thus encouraging the reporting of adverse events and the implementation of actions that prevent their occurrence".
"The adverse event theme needs to be further discussed even during vocational training, whether in the university or in technical courses."
"Professionals must be aware of adverse events." |
| Leitão et al.2424 Leitão IMTA, Oliveira RM, Leite SS, Sobral MC, Figueiredo SV, Cadete MC. Analysis of the Communication of Adverse Events under the Perspective of Assistant Nurses. Rev. da Rede Enferm. do Nord. 2013; 14(6):1073-1083. (2013) |
Qualitative |
To analyze the process of communicating adverse event in the hospital context, from the nurses' perspective |
- Despite report of AE notification, this is threatened, since there is not always notification and adequate case discussion.
- Some nurses reported that the AE registration process is hierarchical, since some communicate the situation to nurse coordinator, although there is a proper form for notification to risk management.
- There is no uniform AE recording, since nurses were not unanimous in the identification of forms and flow.
- The less serious AEs are less reported.
- Finding that the punitive culture still prevails in the occurrence of errors or AE, evidenced by reports of practices of reprimand and punishment of nursing professionals. |
"It is necessary to undertake further research focusing on the issue of the occurrence and and communication of adverse events and their consequences to the service, the professionals, and principally, the patients (…) Promoting reflection and behavioral changes in the workers, structural changes in services and new health policies directed at patient safety."
"Encouraging for the efficient communication of adverse events related to nursing care, which can be ensured through the recording and monitoring risks in the nurse's daily practice, as a means of strengthening the culture of safety and quality" |
Costa et al.2525 Costa VT, Meirelles BHS, Erdmann AL. Best practice of nurse managers in risk management. Rev. Lat. Am. Enfermagem. 2013; 21(5):1165-1171.
(2013) |
Qualitative |
To identify the actions, undertaken by nurse in a risk management program, considered as best practice. |
- Certainty of underreporting by participants. This situation may be related to the fear of punishment, lack of knowledge on the part of employees about the objective of the risk management program, high turnover, hindering the organizational culture about this process.
- In addition, the nurse is who makes the notification most of the time, although the flow of notification is available to all, through electronic and printed medium favoring underreporting. |
"Importance of strategies that involve not only multidisciplinarity and interdisciplinarity, but also the non-fragmentation of processes for continuous improvement and excellence of practices." |
Paiva et al.2626 Paiva MCMS, Popim RC, Melleiro MM, Tronchim DMR, Lima SAM, Juliani CMCM . The reasons of the nursing staff to notify adverse events. Rev. Lat. Am. Enfermagem. 2014; 22(5):747-754.
(2014) |
Qualitative |
To understand the motivation for reporting adverse events from the perspective of nursing staff in the work environment |
- Although the study focused on the reasons for notifying AE, the fact that nurses were appointed as the professionals responsible for reporting was seen by authors as a hindrance for other practitioners to take responsibility for notifying AE.
- Fear reported by some participants, but it was evidenced that the culture of punishment is in transition and the notification is understood auxiliary instrument to manage health care delivery.
- Inconsistencies regarding taxonomy in patient safety. |
"Need to disseminate the WHO taxonomy in patient safety in order to improve the quality of information and encourage reporting."
"Importance of understanding the subjective aspects of nursing professionals' action in the AE reporting system, through knowledge about the expectations and reasons that permeate their decisions and conducts."
"It is necessary to demystify nurse-centered reporting and to promote opportunities for orientation, clarification and encouragement towards participation by all professionals." |
Siqueira et al.2727 Siqueira CL, Silva CC, Teles JKN, Feldman LB. Gerenciamento de risco: percepção de enfermeiros em dois hospitais do sul de Minas Gerais, Brasil TT - Management: perception of nurses of two hospitals in the south of the state of Minas Gerais, Brazil TT - Gestión de riesgos: percepción de los enferme. REME rev. min. enferm. 2015; 19(4):919-926. Available at: http://www.revenf.bvs.br/scielo.php?script=sci_arttext&pid=S1415-27622015000400010.
http://www.revenf.bvs.br/scielo.php?scri...
(2015) |
Qualitativa |
To identify the nurses' perception of risk management and to analyze facilitators and barriers to the operationalization of risk management processes. |
"Statements betrayed the nurses' concealment of errors, whose record can be used against them, and their fear of punishment."
"The participants' statements revealed that adverse events were often underreported because of the lack of time to fill the forms, work overload and the fear of retaliation." |
"Need to reflect on the impact of the adverse event on the health professional, to rethink the underuse of talents in hospitals, to analyze the cost of deaths generated by lack of an effective risk management process, by communication failures and, above all, slow responses." |
Source: Authors (2017).