Análise das ações de melhoria de um sistema de notificação informatizado de incidentes
Data
2021-09-01
Autores
Caroccini, Renata Lima Gonçalves 
Orientadores
Bohomol, Elena
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivo: Analisar as notificações de incidentes classificados como graves e óbitos
oriundos de um sistema de informações sobre segurança do paciente. Método:
pesquisa documental, descritiva, retrospectiva e quantitativa de incidentes notificados
em um sistema de informações. Compõem o estudo 439 notificações do período de
janeiro de 2013 a dezembro de 2018, organizadas em uma planilha híbrida com
elementos de classificação da ferramenta Basado em Análisis Causa-Raiz e The
Conceptual Framework for the International Classification for Patient Safety. Foi
utilizada estatística descritiva e o projeto foi aprovado conforme o parecer 3.802.648
do Comitê de Ética e Pesquisa. Resultados: Os resultados demonstram que as
notificações foram oriundas dos serviços hospitalares (98,8%), da região Sudeste
(76,3%); com certificado de acreditação nível 1 (36,7%). Os pacientes eram idosos
acima de 60 anos (36,7%) e os eventos eram considerados evitáveis (97,1%). A
estratégia mais utilizada para a análise de causas foi a discussão com as equipes
(46,2%). Os relatos apontaram que as causas eram imediatas (68,6%) e estavam
associadas a plano de tratamento inadequado ou inexistente (21,9%); a fragilidade e
a vulnerabilidade foram apontadas como os principais fatores intrínsecos ao paciente
(61,3%); como consequência organizacional, a maioria resultou em aumento adicional
dos recursos para tratamento e exames (43%). As principais ações de melhoria foram:
para o paciente, a disponibilidade de instrução e formação (51%); para os
profissionais, as orientações (30,3%); e para a organização, a melhoria da cultura de
segurança (19,8%). Conclusão: Verificou-se a importância de se analisar os eventos
adversos que trouxeram danos graves e mortes por permitirem entender a urgência
em discutir o assunto nas instituições. Destacou-se a necessidade de implementar
ações que melhorem as condições processuais de trabalho dos profissionais, a
urgência de se aprender com os erros e o desenvolvimento de lideranças para
gerenciar com aspectos tão delicados em relação à vida das pessoas dentro do
sistema de saúde.
Objective: Analyze the notifications of incidents classified as serious and deaths from a patient safety information system. Method: documentary, descriptive, retrospective, and quantitative study on the incidents reported in an information system. The study included 439 notifications from January 2013 to December 2018, which were organized in a hybrid spreadsheet with classification elements from the tools Basado en Análisis Causa-Raiz and The Conceptual Framework for the International Classification for Patient Safety. Descriptive statistics were used and the research project was approved according to opinion 3.802.648 of the Research Ethics Committee. Results: The results show that the notifications came from hospital services (98.8%), from the Southeast region (76.3%); with level 1 accreditation certificate (36.7%). The patients were elderly individuals over 60 years old (36.7%) and the events were considered preventable (97.1%). Team discussion was the most common strategy used for the analysis of causes (46.2%). The reports pointed out that the causes were immediate (68.6%) and were associated with an inadequate or nonexistent treatment plan (21.9%); frailty and vulnerability were pointed out as the main factors intrinsic to the patients (61.3%); an additional increase in resources for treatment and tests was an organizational consequence (43%). The main improvement action for the patient was the availability of instruction and training (51%); for the professionals, guidelines (30.3%); and for the organization, the improvement of the safety culture (19.8%). Conclusion: The study evidenced the importance of analyzing the adverse events that caused serious injuries and deaths, as this allows to understand the urgency of discussing the issue in the institutions. It also highlighted the need to implement actions that improve the procedural working conditions of professionals, the urgency of learning from mistakes, and the development of leaders to manage such delicate aspects related to the lives of people within the health system.
Objective: Analyze the notifications of incidents classified as serious and deaths from a patient safety information system. Method: documentary, descriptive, retrospective, and quantitative study on the incidents reported in an information system. The study included 439 notifications from January 2013 to December 2018, which were organized in a hybrid spreadsheet with classification elements from the tools Basado en Análisis Causa-Raiz and The Conceptual Framework for the International Classification for Patient Safety. Descriptive statistics were used and the research project was approved according to opinion 3.802.648 of the Research Ethics Committee. Results: The results show that the notifications came from hospital services (98.8%), from the Southeast region (76.3%); with level 1 accreditation certificate (36.7%). The patients were elderly individuals over 60 years old (36.7%) and the events were considered preventable (97.1%). Team discussion was the most common strategy used for the analysis of causes (46.2%). The reports pointed out that the causes were immediate (68.6%) and were associated with an inadequate or nonexistent treatment plan (21.9%); frailty and vulnerability were pointed out as the main factors intrinsic to the patients (61.3%); an additional increase in resources for treatment and tests was an organizational consequence (43%). The main improvement action for the patient was the availability of instruction and training (51%); for the professionals, guidelines (30.3%); and for the organization, the improvement of the safety culture (19.8%). Conclusion: The study evidenced the importance of analyzing the adverse events that caused serious injuries and deaths, as this allows to understand the urgency of discussing the issue in the institutions. It also highlighted the need to implement actions that improve the procedural working conditions of professionals, the urgency of learning from mistakes, and the development of leaders to manage such delicate aspects related to the lives of people within the health system.
Descrição
Citação
CAROCCINI, R. L. G. Análise das ações de melhoria de um sistema de notificação informatizado de incidentes. São Paulo, 2021. 124 f. Dissertação (Mestrado em Enfermagem) – Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, 2021