Organizational structure analysis of the Patient Safety Center in hospitals of the Sentinel Network

This is an exploratory and descriptive study with 12 coordinators of the Patient Safety Center. Data were collected using a structured and validated questionnaire with two evaluation domains based on Donabedian’s triad of structure and process.

RESULTS

The Patient Safety Center was implemented in the services with the participation and support of senior management. Human resources and materials are shared with other sectors. Points for improvement were identified regarding the center’s activities, sentinel event prevention, risk management strategies, and professional training.

CONCLUSION

Strategies are needed to ensure a non-punitive culture, event notification, sentinel event prevention, core activities, risk management, and professional training.

Keywords:
Risk management; Patient safety; Hospitals; Nursing; Organization and administration.

Items	FD^* n (%)	PD^† n (%)	PTD^‡ n (%)
The Patient Safety Unit is structured.	9 (75)	1 (8)
Strategies for AE prevention linked to other managers.	6 (50)	6 (50)
Senior management participates in and supports safety culture strategies	9 (75)	3 (25)
Strategies and actions to avoid individual accountability.	6 (50)	5 (42)	1 (8)
Use of quality tools to manage AE risk.	5 (42)	6 (50)
Strategies for risk and event notification included in the Patient Safety Plan	6 (50)	5 (42)	1 (8)
Strategies for disclosing outcomes to the teams.	4 (33)	6 (50)	2 (17)

Items	FD^* n (%)	PD^† n (%)	PTD^‡ n (%)
Promotes activities for risk management.	6 (50)	6 (50)
Develops actions for multidisciplinary integration.	5 (42)	7 (58)
Identifies and evaluates adverse events in processes and procedures.	8 (67)	4 (33)
Develops, deploys, publishes, and updates the patient safety plan.	8 (67)	4 (33)
Accompanies actions linked to the patient safety plan.	6 (50)	6 (50)
Follows patient safety protocols and monitors indicators.	7 (58)	5 (42)
Establishes accident prevention barrier.	8 (67)	4 (33)
Develops, implements, and supervises training programs in patient safety.	3 (25)	8 (67)	1 (8)
Discloses AE and incident review results to management and workers.	6 (50)	4 (42)	1 (8)
Notifies adverse events to the national health inspection service.	5 (42)	5 (42)	2 (16)
Files notifications.	12 (100)
Accompanies health inspection alerts and other risk notifications.	12 (100)

Items	FD^* n (%)	PD^† n (%)	PTD^‡ n (%)	NPD^§ n (%)	NA^\|\| n (%)
Surgical procedures.	7 (58)	4 (34)			1 (8)
Products and devices.	10 (83)	2 (17)
Patient protection.	6 (50)	4 (34)	1 (8)		1 (8)
Care management.	6 (50)	6 (50)
Environmental events.	7 (58)	2 (17)	3 (25)
Radiological events.	6 (50)	2 (17)	2 (17)	1 (8)	1 (8)
Potentially criminal events.	4 (34)	3 (25)	4 (33)	1 (8)

Items	FD^* n (%)	PD^† n (%)	PTD^‡ n (%)	NA^\|\| n (%)
Patient identification.	9 (75)	3 (25)
Encourage hand hygiene.	12 (100)
Safe surgery.	5 (42)	6 (50)		1 (8)
Safety when prescribing, using and administering medication.	4 (34)	7 (58)	1 (8)
Safety in prescribing, using, and administering blood products.	8 (67)	3 (25)
Encouraging patients and their families to get involved in their own safety.	2 (17)	4 (33)	6 (50)
Effective communication.	3 (25)	5 (42)	4 (33)
Pressure wound prevention.	9 (76)	1 (8)	1 (8)	1 (8)
Fall prevention.	9 (75)	3 (25)
Safe use of equipment and materials.	6 (50)	5 (42)	1 (8)
Identifying, analyzing, monitoring, and communicating risk.	5 (42)	7 (58)
Integrating the different risk management processes developed at the service.	1 (8)	10 (84)	1 (8)
Implementing the protocols established by the Ministry of Health.	6 (50)	6 (50)
Safety in prescribing, using, and administering enteral and parenteral nutritional therapies.	8 (67)	1 (8)	2 (17)	1 (8)
Recording the use of orthotics and prosthetics, when used.	8 (67)	2 (17)	1 (8)
Preventing and controlling adverse events, including care-related infection.	10 (83)	2 (17)
Actions to encourage a safe environment.	3 (25)	7 (58)	2 (17)

Items	C^* n (%)	PC^† n (%)	PTC^‡ n (%)	WNC^§ n (%)	NA^\|\| n (%)
Quality and patient safety	6 (50)	5 (42)	1 (8)
Basic principles in patient safety.	5 (42)	3 (25)	4 (33)
Types of care-related adverse events.	6 (50)	3 (25)	3 (25)
Patient safety protocols.	6 (50)	3 (25)	3 (25)
Patient safety indicators.	4 (34)	4 (33)	4 (33)
Strategies for improving quality and safety.	5 (42)	4 (33)	3 (25)
Safety culture.	5 (42)	3 (25)	3 (25)	1 (8)
Patient safety center.	6 (50)	5 (42)		1 (8)
Patient safety plan.	5 (42)	2 (17)	4 (33)	1 (8)
Management and risk management.	8 (67)	3 (25)	1 (8)
Adverse event notification system.	10 (84)	1 (8)	1 (8)
Investigating adverse events.	5 (42)	5 (42)	1 (8)	1 (8)
Root cause analysis.	3 (25)	4 (34)	3 (25)	1 (8)	1 (8)
Failure modes and effects analysis (FMEA)	2 (17)	2 (17)	4 (33)	3 (25)	1 (8)

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[1] Corresponding author:
Renata Soares de Macedo. re_mcd@hotmail.com