Difficulties encountered in the implementation of patient safety protocols in Brazil
DOI:
https://doi.org/10.33448/rsd-v12i2.40178Keywords:
Patient safety; Security protocols; Implementation science.Abstract
Introduction: In 2013, Brazil instituted the National Patient Safety Program (PNSP) to promote and implement a safety culture. Thus, health services became obliged to develop and implement such a program. Objective: To analyze the difficulties encountered by the health team in implementing patient safety protocols in Brazilian health units. Methods: This is an integrative review conducted in the Latin American and Caribbean databases in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), Virtual Health Library (BVS), and Google Scholar through the descriptors, patient safety, patient safety protocols, nursing, and implantation published from 2012 to 2022. Result: The initial search found 43 articles, of which 5 were considered relevant, and 38 were excluded because they were duplicates and/or did not present outcomes of interest due to incomplete data or lack thereof. Conclusion: It is concluded that the health teams found several conditions that hinder the implementation of safety protocols, requiring the participation of senior management in the process and the teams' understanding of these procedures' importance.
References
Agência Nacional de Vigilância Sanitária (2013). Resolução - RDC nº 36, de 25 de julho de 2013. Institui ações para a segurança do paciente em serviços de saúde e dá outras providências. Brasília (DF). Ministério da Saúde.
Batalha, E. M. S. da S., & Melleiro, M. M. (2016). Cultura de segurança do paciente: percepções da equipe de enfermagem. HU Revista, 42(2). https://periodicos.ufjf.br/index.php/hurevista/article/view/2518.
Bordignon, M., Monteiro, M. I., Mai, S., Martins, M. F. S. V., Rech, C. R. A., & Trindade, L. L. (2015). Oncology nursing professionals' job satisfaction and dissatisfaction in Brazil and Portugal. Texto Contexto Enferm. 2015;24(4):925-33. doi: http://dx.doi.org/10.1590/0104-0707201500004650014.
Brasil 2013. Ministério da Saúde (BR). Portaria n° 529, de 1º de abril de 2013. Institui o Programa Nacional de Segurança do Paciente. Brasília (DF).
Brasil. (2014). Documento de referência para o Programa Nacional de Segurança do Paciente. Fundação Oswaldo Cruz; Agência Nacional de Vigilância Sanitária. Brasília (DF): Ministério da Saúde.
Brasil (2016). Implantação do Núcleo de Segurança do Paciente em Serviços de Saúde – Série Segurança do Paciente e Qualidade em Serviços de Saúde/Agência Nacional de Vigilância Sanitária – Brasília (DF): ANVISA.
Cho, E., Lee, N-J., Kim, E-Y., Kim, S., Lee, K., Park, K-O. et al. (2016). Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: a cross-sectional study. Int J Nurs Stud. 60: 263-71. doi: https://doi.org/10.1016/j.ijnurstu.2016.05.009.
Duarte, S. C. M., Stipp, M. A. C., Silva, M. M. & Oliveira, F. T. (2015). Adverse events and safety in nursing care. Rev Bras Enferm. 68(1):144-54. doi: https://doi. org/10.1590/0034-7167.2015680120p.
Fagerström, L., Kinnunen, M., & Saarela, J. (2018). Nursing workload, patient safety incidents and mortality: an observational study from Finland. BMJ Open. 2018;8:e016367. doi: https://doi.org/10.1136/bmjopen-2017-016367.
Faustino, T. N. et al. (2021). National Patient Safety Program in Brazil: Incidents Reported Between 2014 and 2017. J Patient Saf. 17(8):e1202-e1208. doi: 10.1097/PTS.0000000000000496. PMID: 29781981.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: building a safer health system. Washington, D. C.: Institute of Medicine/National Academy Press; 2000.
Macedo, T. R., Rocha, P. K., Tomazoni, A., Souza, S., Anders, J. C., & Davis, K. (2016). The Culture Of Patient Safety From The Perspective Of The Pediatric Emergency Nursing Team. Revescenferm Usp. 2016;50(5):756-762. Doi: Http://Dx.Doi.Org/10.1590/S0080-623420160000600007
Nieva, V. F., & Sorra J. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Quality & Safety Health Care. V.12, Suppl 5, p. 17-23, dez. 2003. http://dx.doi.org/10.1136/qhc.12.suppl_2.ii17
Ocloo, J., Garfield, S., Franklin, B. D., & Dawson, S.(2021). Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews. Health Res Policy Syst. 2021 Jan 20;19(1):8. doi: 10.1186/s12961-020-00644-3.
Portulhak, H., Espejo, M. M. S. B., & Pacheco, V. (2018). Public value scorecard: alternativa para avaliação de desempenho em hospitais universitários. Rev Admin Hosp Inov Saúde. 2018;15(1):110-26. doi: https://doi.org/10.21450/rahis.v15i1.4780.
Rafter, N., Hickey, A., Conroy, R. M., Condell, S., O'Connor, P., Vaughan, D. et al. (2017). The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals: a retrospective record review study. BMJ Qual Saf. 26:111-9. doi: https://doi.org/10.1136/bmjqs-2015-004828.
Reis, G. A. X., Hayakawa, L. Y., Murassaki, A. C. Y., Matsuda, L. M., Gabriel, C. S., & Oliveira, M. L. F. (2017). Nurse manager perceptions of patient safety strategy implementation. Texto Contexto Enferm. 2017;26(2):e00340016. doi: https://doi.org/10.1590/0104- 07072017000340016.
Silva-Batalha, E. M. S., & Melleiro, M. M. (2016). Cultura de segurança do paciente: percepções da equipe de enfermagem. HU Revista. 2016;42(2):133-42. http://ojs2.ufjf.emnuvens.com.br/hurevista/article/ view/2518/872.
Silva, A. C. M. R., Loures, P. V., Paula, K. X., Santos, N. A. R. & Perígolo, R. A. (2017). Importância do núcleo de segurança do paciente: um guia para implantação em hospitais. Rev. Educ. Meio Amb Saúde. 7(1): 87-109. http://www.faculdadedofuturo.edu.br/revista1/index.php/remas/article/ view/134/205.
Souza, M. T., Silva, M. D. da., & Carvalho, R. (2010). Integrative review: what is it? How to do it? einstein (São Paulo). 2010 Jan;8 (einstein (São Paulo), 2010 8(1)). https://doi.org/10.1590/S1679-45082010RW1134.
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