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Segurança do doente : da teoria à prática clínica
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RESUMO - A investigação dos últimos 10 anos mostra que pelo menos 10 % dos doentes admitidos em
estabelecimentos hospitalares vão sofrer danos decorrentes da prestação dos cuidados de
saúde. É da responsabilidade do profissional de saúde evitar que isso aconteça. No entanto,
poucos profissionais registam os seus erros e menos ainda são os que os analisam, o que
dificulta a aprendizagem e a prevenção de ocorrências semelhantes no futuro.
Paradoxalmente, o primeiro passo para a criação de um sistema eficaz de promoção da
segurança do doente é aumentar a visibilidade do erro e da lesão decorrentes dos cuidados
de saúde. Para isso concorrem os sistemas de relatos de incidentes, as auditorias, a revisão
de processos e a monitorização de indicadores clínicos. A análise dos dados obtidos
permite identificar as áreas que necessitam de medidas de correcção, bem como planear
a sua implementação. Em dois hospitais do Centro Hospitalar de Lisboa Central (CHLC),
o sistema de informação de segurança do doente conta, desde 2003, com cerca de 5 mil
relatos de incidentes feitos pelos vários profissionais de saúde. A informação gerada,
associada à que é fornecida pelas auditorias clínicas e pelos indicadores clínicos, tem sido
aplicada na reorganização de processos e procedimentos, e na implementação de medidas
correctivas. O evento adverso tornou-se também mais visível para o próprio doente, que
espera da instituição e dos profissionais maior abertura na comunicação dos problemas
surgidos durante os cuidados. A avaliação de risco, a prevenção do erro e a promoção da
segurança do doente fazem já parte do currículo pré e pós graduado dos profissionais de
saúde do CHLC.
ABSTRACT - Medical literature from the last ten years shows that at least 10 % of patients admitted to Healthcare Services will suffer some kind of harm. Healthcare workers should be held responsible for the prevention of potential harm to patients whenever possible. And yet, carers who record their own errors are few and still fewer are those who will analyse them thus allowing for some learning to be gained and similar incidents to be prevented in the future. The first step in promoting patient safety is increasing the visibility of errors and patient harm. Patient safety information systems rely on incident reporting, audits, clinical indicators and process reviewing to achieve that goal. Data analysis can then identify clinical areas needing improvement, for corrective measures to be put in place. In Centro Hospitalar de Lisboa Central (CHLC), the patient safety information system received over five thousand incident reports from different professional groups since 2003. Information was also gathered from audits and clinical indicators and allowed for several processes and procedures to be redesigned and improvement projects to be implemented. Adverse events have also become more visible to the patient, who expects healthcare professionals to openly disclose problems during care. The undergraduate and postgraduate curriculum in the CHLC now includes training in risk analysis, medication errors and patient safety.
ABSTRACT - Medical literature from the last ten years shows that at least 10 % of patients admitted to Healthcare Services will suffer some kind of harm. Healthcare workers should be held responsible for the prevention of potential harm to patients whenever possible. And yet, carers who record their own errors are few and still fewer are those who will analyse them thus allowing for some learning to be gained and similar incidents to be prevented in the future. The first step in promoting patient safety is increasing the visibility of errors and patient harm. Patient safety information systems rely on incident reporting, audits, clinical indicators and process reviewing to achieve that goal. Data analysis can then identify clinical areas needing improvement, for corrective measures to be put in place. In Centro Hospitalar de Lisboa Central (CHLC), the patient safety information system received over five thousand incident reports from different professional groups since 2003. Information was also gathered from audits and clinical indicators and allowed for several processes and procedures to be redesigned and improvement projects to be implemented. Adverse events have also become more visible to the patient, who expects healthcare professionals to openly disclose problems during care. The undergraduate and postgraduate curriculum in the CHLC now includes training in risk analysis, medication errors and patient safety.
Descrição
Palavras-chave
Incidentes Segurança do doente Erro médico Melhoria dos cuidados Incidents Patient safety Medical errors Improvement
Contexto Educativo
Citação
Lage, Maria João - Segurança do doente : da teoria à prática clínica = Patient safety meets clinical practice. Revista Portuguesa de Saúde Pública. ISSN 0870-9025. Volume temático, Nº 10 (2010), p. 11-16
Editora
Universidade Nova de Lisboa, Escola Nacional de Saúde Pública