Notificação de incidentes: barreiras e estratégias para promover a cultura de segurança

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

Acessibilidade / Reportar erro

Brasil

Revista da Escola de Enfermagem da USP

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

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

Notificação de incidentes: barreiras e estratégias para promover a cultura de segurança

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Objetivo

Identificar as barreiras da subnotificação, os fatores que motivam o relato e as estratégias para promover os registros de incidentes.

Método

Por meio de rodas de conversas e a presença de um mediador, a equipe multidisciplinar do hospital, composta por 65 profissionais, foi estimulada a falar sobre tema.

Resultado

Complacência e ambição são barreiras superadas. Falta de responsabilidade sobre notificação foi a nova barreira observada. Há uma crença de que apenas a enfermagem é responsável pela notificação.

Conclusão

As estratégias para motivar os registros foram retornos das notificações relatadas (feedback), intervenções educativas na equipe de saúde, ferramentas simplificadas para notificação (manual ou eletrônica), com informações mínimas necessárias para a equipe de saúde otimizar o processo e o tempo de notificação. Para a garantia da qualidade do relato, a equipe de gerenciamento da segurança poderia melhorar ou complementar o relato.

Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos; Atitude do Pessoal de Saúde; Segurança do Paciente; Gestão da Segurança; Sistemas de Notificação de Reações Adversas a Medicamentos; Farmacovigilância

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

Acompanhe os números deste periódico no seu leitor de RSS

[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