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Sistema de notificação de eventos adversos : contributos para a melhoria da segurança do doente
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RESUMO - Este estudo insere-se na temática dos sistemas de notificação de eventos adversos.
Pretende-se compreender a necessidade e importância de implementação de um sistema
de notificação de Eventos Adversos num hospital E.P.E. (entidade pública empresarial) de
Lisboa.
Apresenta como objectivo geral:
•Identificar as principais características que um Sistema de Notificação de Eventos
Adversos, Erros e Incidentes deve ter e com base nisso propor um formulário de notificação
que assente numa lógica de aprendizagem e não numa perspectiva de culpabilização.
Trata-se de um estudo exploratório, descritivo, quantitativo, transversal. Foi utilizado como
instrumento de recolha de dados o inquérito por questionário.
A amostra é constituída por 82 enfermeiros de um hospital de Lisboa, em que não está
implementado sistema de notificação de eventos adversos.
Após análise dos dados concluiu-se que:
Quando ocorrem acontecimentos indesejáveis, os profissionais de enfermagem
poucas vezes notificam;
Os profissionais notificam com maior frequência quando o evento é grave e trágico;
Os inquiridos apontam como principais factores para a ocorrência de eventos
adversos/erros/incidentes no seu local de trabalho “falhas de comunicação” e
“deficiente rácio enfermeiro/doente”;
A maior parte dos inquiridos concorda com a implementação de um sistema de
notificação de eventos adversos, erros e incidentes no hospital onde trabalham. O
sistema deve ser de carácter obrigatório assegurando o anonimato.
Espera-se que o presente trabalho seja um contributo importante, que entronque e potencie
a política/estratégia definida pelo hospital para a área da segurança do doente.
ABSTRACT - This research study is part of the issue of Reporting Systems of Adverse Events. With this study is to understand the need and importance of implementing a System of Reporting Adverse Events in a hospital in Lisbon. Presented as objective: • Identify the main characteristics of a Reporting System of Adverse Events must have and in this basis propose a notification form of adverse events, errors and incidents based on a logic of learning and not penalty. It is an exploratory, descriptive, quantitative and transversal study. It was used as a tool for collecting data a survey by a questionnaire. The study was applied to 82 nurses from a hospital Lisbon where is not implemented a Reporting System. After collecting and analyzing data it was concludes that: When undesirable events occur, nurses rarely carry their notification. The professionals most frequently performed the registration or notification when the event / occurrence is serious. The professionals point out as main factors for the occurrence of adverse events / errors / incidents in the workplace: the communication gaps and the poor ratio of professional nursing / patient. Nursing professionals agree on the implementation of a system of notification of events / occurrences in the hospital where they work, which is anonymous in nature and binding. It is hoped that this work is an important contribution wich empower the policy/strategy defined by the hospital to the area of patient safety.
ABSTRACT - This research study is part of the issue of Reporting Systems of Adverse Events. With this study is to understand the need and importance of implementing a System of Reporting Adverse Events in a hospital in Lisbon. Presented as objective: • Identify the main characteristics of a Reporting System of Adverse Events must have and in this basis propose a notification form of adverse events, errors and incidents based on a logic of learning and not penalty. It is an exploratory, descriptive, quantitative and transversal study. It was used as a tool for collecting data a survey by a questionnaire. The study was applied to 82 nurses from a hospital Lisbon where is not implemented a Reporting System. After collecting and analyzing data it was concludes that: When undesirable events occur, nurses rarely carry their notification. The professionals most frequently performed the registration or notification when the event / occurrence is serious. The professionals point out as main factors for the occurrence of adverse events / errors / incidents in the workplace: the communication gaps and the poor ratio of professional nursing / patient. Nursing professionals agree on the implementation of a system of notification of events / occurrences in the hospital where they work, which is anonymous in nature and binding. It is hoped that this work is an important contribution wich empower the policy/strategy defined by the hospital to the area of patient safety.
Descrição
Palavras-chave
Segurança do doente Sistema de notificação de eventos adversos Eventos adversos Erros Incidentes Patient safety Reporting system Adverse events Errors Incidents
Contexto Educativo
Citação
Editora
Universidade Nova de Lisboa. Escola Nacional de Saúde Pública