BRAZILIAN NETWORK FOR NURSING AND PATIENT SAFETY: CHALLENGES AND PERSPECTIVES

This study’s aim was to describe the experience of implementing the Brazilian Network for Nursing and Patient Safety, as well activities intended to disseminate a culture of patient safety in health and educational institutions. This is an experiment report. The Brazilian Network was completed six years ago and, since its establishment, has promoted actions always in consonance with the objectives of the International Network for Nursing and Patient Safety and the World Alliance for Patient Safety. Networks proposed by the Pan American Health Organization corroborated the actions taken by the Brazilian Network. These actions have been successful, as every year new members are added and new Centers are established, while the Network has participated in academic, scientific and government activities. The challenge lies in increasing the impact of these actions to implement safe practices effectively in healthcare facilities. DESCRIPTORS: Patient safety. Nursing. Quality assurance health care. Quality of health care. LA RED BRASILERA DE ENFERMERÍA Y SEGURIDAD DEL PACIENTE: DESAFÍOS Y PERSPECTIVAS RESUMEN: Este estudio tiene como objetivo describir la experiencia de la implementación de la Red Brasileña de Enfermería y Seguridad del Paciente, así como las actividades realizadas para difundir la cultura de seguridad del paciente en las instituciones de salud y de enseñanza. Se trata de un relato de experiencia. La Red tiene seis años. Desde sus inicios viene desarrollando acciones siempre en consonancia con los objetivos de la Red Internacional de Enfermería y Seguridad del Paciente y la Alianza Mundial para la Seguridad del Paciente. Se entiende que el trabajo en redes propuestas por la Organización Panamericana de la Salud corroboró las medidas adoptadas por la Red Brasileña que pueden considerarse un éxito, teniendo en cuenta que, cada año se da la inclusión de nuevos miembros, la apertura de nuevos polos y núcleos y la participación de la Red en actividades académicas, científicas y gubernamentales. El desafío consiste en aumentar el impacto de este tipo de acciones con el fin de efectuar la práctica segura en las instituciones de salud. DESCRIPTORES: Seguridad del paciente. Enfermería. Garantía de la calidad de atención de salud. Calidad de la atención de salud. 906 http://dx.doi.org/10.1590/0104-070720150001980014


INTRODUCTION
Patient safety can be defined as the absence of potential or unnecessary harm to patients associated with healthcare delivery and the ability of healthcare facilities to adapt to human and operational risks inherent to the work process. 1 Ensuring quality healthcare services implies processes that ensure that clinical care meets established criteria or standards.Some of the basic principles of quality are continuous prevention and improvement. 2oncerns related to "Patient Safety" have been on the agenda since 1863 when Florence Nightingale expressed such a concern in her book "Notes on hospitals".Great advancement took place in the 1990s when James Reason made an important contribution to the understanding of how mistakes occur when he highlighted that mistakes are a result of a failure in the system and for this reason should be addressed from a holistic point of view. 3eason's studies became known in 1999 with the Institute of Medicine (IOM) report, titled: To err is human: building safer healthcare, which generated a great impact and strongly influenced the world movement toward patient safety. 4The report drew the health institutions' attention to the need to strengthen the culture of safety at an organizational level, as a measure essential to the process of improving patient safety in the hospital context. 5Achieving sustainable improvements in patient safety, however, can be difficult.Specific measures, as well as professional training, teamwork and the establishment of facilities prepared to ensure patient safety have been associated with improvement in the culture of safety. 6n 2004, the World Health Organization (WHO) created the project "World Alliance for Patient Safety", with the objective of drawing attention to the improvement of patient safety within healthcare and to political commitment, in addition to supporting the development of patient safety-related public policies and practices around the world. 7Since then, the Pan-American Health Organization (PAHO) has proposed Latin America to cooperate in order to accomplish the actions provided in the "World Alliance for Patient Safety".
One of the actions of greatest impact in Brazil was implemented in 2007, when the National Health Surveillance Agency (ANVISA) 8 established a proposal to identify the specific types and nature of safety problems in health services in order to comply with WHO recommendations.
This same agency, in partnership with the Ministry of Health, launched the National Program for Patient Safety in April 2013, 9 the purpose of which is to promote and support the implementation of initiatives directed to patient safety in different areas of care delivery, organization and the management of healthcare delivery, through the implementation of risk management and Patient Safety Centers in Brazilian health facilities.
One study was performed to systematize the recommendations of nursing professionals to improve patient safety and listed suggestions to improve procedures and working processes based on current patient safety principles such as: the establishment of protocols, risk barriers, patient identification, unit dose dispensing and double checking.There are also recommendations that involve professional behavior, such as dedication, commitment and awareness at work, respect and consideration. 10In regard to professional behavior, studies also stress that failures in communication when delivering care and problems with the content and reliability of information transferred through different settings have been identified as threats to patient safety. 11he services provided within the field of nursing play an important role in the search for quality in healthcare organizations, given the number of professionals working in these institutions and their responsibility in providing 24-hour care. 12he combination of nursing competencies and training can be linked to the evolution of patients' conditions.One study showed a lower rate of mortality during hospitalizations for a variety of surgical patients in hospitals with a greater number of trained and qualified nurses. 13Regardless of one's level of education, qualification and a continuous search for tools to update knowledge and participation in actions that promote patient safety can play a role in the evolution of patients' conditions.
There were numerous strategies adopted at a world level in order to improve the context of safety in health services.Note that in 2005, PAHO's Human Resources for Health Unit created the International Network of Nursing and Patient Safety (RIENSP), in Concepción, Chile, with the objective to outline tendencies and priorities in the development of nursing related to "Patient Safety" and discuss cooperation and information exchange among nations and the need to strengthen evidence-based practice.
The challenges in the nursing field in regard to this topic include: the creation of Patient Safety Committees in healthcare facilities, composed of multidisciplinary teams in order to develop a safety culture within institutions and strengthening Nursing and Patient Safety Networks promoting rapid and effective communication of evidence, experiences and recommendations so that patient safety is ensured around the world. 14etworks are considered by the PAHO/ WHO to be important mechanisms that enable the exchange of information and experiences and the valorization of communication processes, in addition to being a constant exchange of knowledge among stakeholders.In this sense, a network is valued as an important strategy to support activities and implement effective public health actions. 15ven though improvements have been observed in terms of safety policies, people are still exposed to various risks when receiving healthcare.This study's aim was to describe the experience of implementing the Brazilian Network for Nursing and Patient Safety (REBRAENSP), as well as the activities developed to disseminate a culture of patient safety in healthcare and teaching institutions.REBRAENSP's work is structured in hubs and centers, the main purpose of which is to disseminate the importance of cultural changes and the implementation of a culture of patient safety in institutions.According to the one who conceived it, Silvia Helena de Bortoli Cassiani, REBRAENSP is based on the belief that networks imply solidarity, trust and respect for knowledge and experience.

BRAZILIAN NETWORK FOR NURSING AND PATIENT SAFETY
It has been six year since REBRAENSP creation.It has had, since its creation, the involvement and participation of nurses from diverse regions of Brazil, who have enriched the discussions intended to clarify its objectives and develop its work plan, always in agreement with the RIENSP and the World Alliance for Patient Safety's objectives.
The network's first meeting included the presence of 15 nurses from various Brazilian regions.It is currently composed of more than 600 nurses, distributed in 24 centers or hubs in Brazilian states and cities (Figure 1) and is still increasing its coverage.

Developed actions
REBRAENSP encourages and supports the establishment of new Hubs and Centers through public speaking, ample dissemination through social networks and e-mail, as well as through a newly constructed website. 16This permits the dissemination of information and knowledge related to the nursing field and patient safety, aiming to disseminate all the activities developed by the Hubs or Centers and national and international policies related to the topic.
The logotype was created in 2008 to disseminate the name of the network nationally and internationally and associate its image with REBRAENSP (Figure 2).

Figure 2 -Logotype of the Brazilian Network for Nursing and Patient Safety
Periodical meetings are held in different places to which the coordinators of REBRAENSP's hubs and centers are invited, while the participation of other nurses interested in becoming familiar with the network or becoming a member is also encouraged in these meetings to promote opportunities for them to meet personally.
Note that the Network's coordination and members participate in annual meetings promoted by RIENSP, which always take place at the same time the Pan-American Nursing Colloquiums are held.
These meetings enable members to identify and analyze potential barriers, interests, and priorities related to practice, management, investigation, and education in the field of nursing.Together, all the Hubs and Centers spread throughout Brazil, work with common goals and objectives, such as enhancing the development of multicenter investigations among members, sharing methodologies, and technological resources directed to the activities of care-delivery management, education, investigation, and technical cooperation related to nursing and patient safety.
The greatest challenge is to strengthen the presence of patient safety as a topic in nursing undergraduate and graduate programs and also in vocational/technical high school programs.Another challenge is to enable students to develop research that not only identifies the current context in Brazil related to patient safety, but also analyzes different strategies to introduce patient safety within teaching and care-delivery settings.
In 2013, the Network helped with the public consultation promoted by the Ministry of Health and Anvisa concerning the National Program of Patient Safety and safe surgery protocols, prevention of pressure ulcers, the practice of hand-washing in health services, falls prevention, patient identification, and safety in drug prescription, use and administration.A document directed to AN-VISA was also developed in order to strengthen the participation of the Network in the implementation process of the National Program for Patient Safety.In this document, the Network states it's willingness to help and compose the group that will implement the Program and also develop educational material to help professionals deliver safe and quality care.
The creation of the REBRAENSP's website is considered an advancement, 16 because the Hubs and Centers' coordinators can disseminate their actions through it and contribute to the dissemination of information related to national programs, material, and events, among other items.
The Hub in São Paulo, in partnership with the Patient Safety Program from the Regional Council of Nursing at São Paulo (CORENSP) and the board of the Brazilian Nursing Association in São Paulo (ABEn-SP), on April 6 th 2010 developed the "Declaration of the State of São Paulo Nursing for the Promotion of Patient Safety".The document was written to declare the commitment of the nursing association in São Paulo to develop actions promoting patient safety in the spheres of education, clinical practice, research and organizational culture, based on the profession's ethical and legal precepts. 17n 2010, It also published the booklet "10 steps toward patient safety" 18 jointly with CO-RENSP.In 2011, new material was disseminated titled "Medication errors: definitions and prevention strategies". 19This kind of material is widely disseminated through social networks, websites, and meetings addressing patient safety.
The book "Patient Safety Strategies: manual for healthcare workers", was developed in 2013 by the REBRAENSP team -the hub in Rio Grande do Sul. 20It's available as a download, free of cost on the Network's website.

Work plan for 2014-2016
One of the strategies adopted by the Network to operationalize actions is the development of national and local work plans.The REBRAENSP's work plans are outlined every three years based on recommendations contained in the RIENSP's work plan adapted to the Brazilian context.The objective is to promote the dissemination of the topic concerning nursing and patient safety among workers, health institutions and representatives of organized society.
This plan consist of six fields: nursing qualification, communication extended to communities, investigation and dissemination of knowledge, public policies, nursing services and the Network's expansion and strengthening.Each coordinator, together with the members of REBRAENSP's Hubs and Centers, must discuss and describe the plan according to the possibility of each one implementing it.The work plan, as well as its results, is represented by the coordinator or representative in REBRAENSP's six-month meetings and in local meetings held by each Hub or Center according to its schedule.
REBRAENSP's goals and respective strategies established for 2014 to 2016 are presented in table 1.

CONCLUSION
It is believed that creating networks is the most efficacious strategy to establish the means in Brazil to disseminate and consolidate the patient safety culture in healthcare organizations, teaching and research institutions, non-governmental organizations, programs directed to patients and family members to strengthen the delivery of safe and quality nursing care.
REBRAENSP was founded on May 14 th , 2008, after the creation of RIENSP in November 2005, in meetings promoted by the Nursing Program of the PAHO's Human Resources for Health Unit.It is a strategy to establish connections, cooperation and synergy among people and institutions interested in the joint development of healthcare delivery, management, research, information and education, in order to contribute to patient safety.

Field 2 :
communication extended to communities and societies Promote events including discussions and reflections regarding patient safety.Create on-going forums promoting multidisciplinary discussions with the participation of members of community organizations linked to the Municipal Councils of Health.Develop and administer patient safety-related lectures and speeches.

Field 3 :Field 4 :
investigation and dissemination of knowledge Conduct research addressing patient safety.Maintain the website www.rebraensp.com.brupdated.public policies Participation in the development of policies.

Field 5 :
nursing services and patient safety Promote discussions and the dissemination of patient safety protocols launched by the Ministry of Health: •patient identification •safe surgery •falls prevention •prevention of pressure ulcers •safe drug administration •hands washing Contribute to the implementation of Patient Safety Centers in healthcare facilities.

Field 6 :
network expansion and strengtheningCreate and develop new REBRAENSP hubs and centers.

Table 1 -REBRAENSP's work plan for 2014 to 2016 Goals Strategies Field
1: nursing education and patient safetyMobilize schools' managers to include the topic of patient safety in the curricula of nursing undergraduate, graduate programs and also in vocational/technical programs.Contribute to professional qualification that strengthens the National Program for Patient Safety.