PATIENT SAFETY AN ANALYSIS TO EVENT NOTIFICATION

Authors

• Ana Paula Agostinho Alencar Universidade Estadual do Ceará http://orcid.org/0000-0002-6262-4279
• Rhanna Emanuela Fontenele Lima de Carvalho Universidade Estadual do Ceará https://orcid.org/0000-0002-3406-9685

DOI:

https://doi.org/10.17058/rips.v8i2.19298

Keywords:

Patient Safety;, Event Notification;, Health Care;

Abstract

Introduction: patient safety is a global issue in management agendas, justified by the incidence of failures related to health care. Method: retrospective, descriptive and quantitative study, carried out in a type II Polyclinic of specialized care in the State of Ceará. Data were collected in January 2023. The sample consisted of 21 spontaneous notifications, made from June to December 2022. After collection, the data were organized in the Microsoft Excell® 14.0 version 2010 program, analyzed by simple descriptive statistics and presented in graphs. The research was approved by the Ethics Committee under the Opinion number: 5.969.403. Results: Regarding the causes of errors, notifications related to methods prevailed (47.6%), followed by methods and people (28.6%), and people-related (14.3%). The predominant types of events were nonconformities (46.20%), followed by events without harm and minor harm (9.5% each). Regarding the sectors notified, the ones that stand out are those with direct management by nursing, observation and invasive exams (28.6% of the notifications), and the Sterilization Material Center (14.3%). Regarding the notifying sectors, the warehouse made 28.6% of the notifications, the pharmacy 23%, quality 14.3%, reports, colonoscopy and endoscopy made 9.5% each. Conclusion: failures and errors can be associated mostly with causes linked to people and methods, that is, directly related to behavioral attitudes.

approved by the Ethics Committee under Opinion number: 5,969,403. Results: regarding the investigation of the causes interrelated to the notifications, notifications related to methods prevailed (10; 47,6%), followed by methods and people with (6; 28,6%) and related to people with (n=3; 14,3%). The types of events according to the notifications made are seen with a predominance of non-conformities contained in (n=16; 46.20%) of the notifications, then it is verified that (n=2; 9.5%) of events without damage and ( n=2; 9.5%) with light damage. Among the notified sectors, those directly managed by nursing stand out, presenting (n=6; 28.6%) notifications to Nursing, and then (n=3; 14.3%) to the Sterilization Material Center. As for the reporting sectors, the warehouse carried out (n=6; 28.6%) notifications, followed by the pharmacy (n=5; 23%) the quality sector carried out (n= 3; 14.3%) notifications and an equal number of notifications (n=2; 9.5%) reports, colonoscopy and endoscopy. Conclusion: failures and errors can be mostly associated with causes linked to people and methods, that is, directly related to behavioral atitudes.

Keywords: Patient safety; Event Notification; Health Care.

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