Gestão de riscos para segurança do paciente: o enfermeiro e a notificação dos eventos adversos

Abstract

This study deals with risk management as a strategy for patient safety. Its object of study the process of notification of adverse events. The objectives were: to identify the knowledge of nurses about adverse events, risk management and patient safety; describe, starting from nurses reports, their actions toward the occurrence of adverse events in the setting of their work; to describe the advantages and difficulties faced by nurses to the adverse event notification. It was used as a study methodology exploratory qualitative approach, whose scenario was a public general hospital located in a city in Zona da Mata mineira. As a theoretical framework, we used studies of patient safety, risk management and reporting incidents and adverse events. Data collection was conducted through semi-structured interviews, from november to december 2014, with 20 nurses who perform their labor activities of the service, and the answers were analyzed using content analysis technique, emerging three thematic categories: knowledge of nurses about adverse events, risk management and patient safety; do the nurse before an adverse event; and facilities and difficulties encountered by nurses in adverse event notification. The results showed that nurses dominate the adverse event issues, risk management and patient safety. The applicability of the steps of adverse event reporting process, clarified that the notification of adverse events is a daily practice of nurses, however, the statements of some professionals, found gaps in the notification, which favor underreporting of adverse events. The subject of discourse thematic analysis also allowed to express that during the process of notification of adverse events, the nurse is faced with aspects that facilitate and hinder this process. There were considered to professional attitudes favorable to the notification and also those that affect the success of adverse event notification process, deserving focus on training, which can be used as a tool to assist in improving patient safety.