Notificación de incidentes: barreras y estrategias para promover la cultura de seguridad

Varallo, Fabiana Rossi; Passos, Aline Cristina; Nadai, Tales Rubens de; Mastroianni, Patricia de Carvalho

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Revista da Escola de Enfermagem da USP

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Sumário

ORIGINAL ARTICLE • Rev. esc. enferm. USP 52 • 2018 • https://doi.org/10.1590/S1980-220X2017026403346 copiar

Notificación de incidentes: barreras y estrategias para promover la cultura de seguridad

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo

Identificar las barreras de la subnotificación, los factores que motivan el relato y las estrategias para promover los registros de incidentes.

Método

Mediante ruedas de conversación y la presencia de un mediador, el equipo multidisciplinario del hospital, compuesto de 65 profesionales, fue estimulado a hablar acerca del tema.

Resultado

Complacencia y ambición son barreras superadas. Falta de responsabilidad acerca de la notificación fue la nueva barrera observada. Existe una creencia de que solo la enfermería es responsable de la notificación.

Conclusión

Las estrategias para motivar los registros fueron retornos de las notificaciones relatadas (feedback), intervenciones educativas en el equipo sanitario, herramientas simplificadas para notificación (manual o electrónica), con informaciones mínimas necesarias para que el equipo sanitario optimice el proceso y el tiempo de notificación. Para la garantía de la calidad del relato, el equipo de gestión de la seguridad podría mejorar o complementar el relato.

Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos; Actitud del Personal de Salud; Seguridad del Paciente; Gestión de la Seguridad; Sistemas de Registro de Reacción Adversa a Medicamentos; Farmacovigilancia

Causes	Perceptions
GUILT	There is a feeling of guilt for being responsible for the occurrence of an incident. Reports may indicate an inappropriate practice during the healthcare procedures (“I could reveal inconsistencies). Furthermore, professionals reported uncomfortable situations in reporting incidents by a coworker. The report would impair the career of the colleague due to evidence of incompetence or negligence regarding institutional protocols (“I could reveal the incompetence of my colleague with my report”).
IGNORANCE	Ignorance is related to incident reporting (“I do not know what or how to report”, “I have no knowledge about what to report”, “I do not know where to find the reporting form”, “I do not know where to send the reporting form”, “I did not know that the multidisciplinary team can file reports”). Moreover, several professionals report only serious incidents (“I report just the most serious incidents for patients”, “The incident does not impact the patient in that moment, so I did not report it”, “If we solve the non-serious incidents , we do not report them”), since reporting process wastes time, and healthcare is a priority when compared with filling out documents (“Pharmacovigilance and technical surveillance reporting forms have a lot of information. Even if they were mostly ordinary incidents, we would have to take time to fill them out”).
DIFFIDENCE	A lack of causal evidence also leads to underreporting (“I am not sure about which drug was responsible for the incident”).
INDIFERRENCE	The lack of feedback and the absence of the culture of reporting are important barriers (“Culturally, Brazilian professionals do not file reports. I worked at another health institution and nobody filed reports there”, “I do not know what happens with my report”, “I do not file reports because I do not see changes in my work routine”). Complexity in filling out reporting forms is also a hindrance (“The reporting form is too long”, “The reporting form gives me more work”). Besides filling out the form, incidents must be registered in medical records and in an institutional document (“We must report incidents twice, which wastes my time and I have other priorities”).
LACK ACCOUNTABILITY	Nursing staff has the responsibility to file reports (“I identify the incident and communicate it to the nurse”, “Nursing staff must fill out the reporting form”). Therefore, responsibility always belongs to another person. However, nursing staff does not file reports because they are overworked and have no time (“My commute is six hours, but I must manage 24 hours. Even if other professionals identify the incident, I will forget to report it”).

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Patricia de Carvalho Mastroianni. Universidade Estadual Paulista, Faculdade de Ciências Farmacêuticas, Campus Araraquara, Rodovia Araraquara-Jaú, Km 1, s/n, Campus Ville CEP 14800-903 – Araraquara, SP, Brazil. patriciamastroianni@yahoo.com.br