Abstract
ABSTRACT Objective: to identify how nurses report adverse events; to know what elements influence adverse event reporting and which reporting strategies they suggest. Method: qualitative study with a convergent care research design, conducted in a critical patient unit of a private health center in the region of Magallanes, Chile. Thirteen nurses participate in the study, through interviews and a discussion group. Results: the nurses who report adverse events do so verbally and in writing to the nurse coordinator immediately. Failure to report adverse events is mainly due to lack of knowledge of the safety culture, fear of reprisals and punishment within the workplace. As adverse event reporting strategies, they suggest continuing education about the safety culture, raising awareness and trust in that error reporting will not be met with punishment and that the error will lead to an improvement plan that avoids committing the same error on another occasion, improving communication and leadership. Conclusion: although nurses report adverse events, they are concerned with punishment, indicating the need to review the patient safety culture at a critical care unit in the study context.
Highlights
The occurrence of care and nursing care-related errors / adverse events is closely related to the adoption of a safety culture
The nurses emphasize that adverse events occurred at the critical care unit are reported both verbally and in writing
It is informed through an incident sheet, which is analyzed and improvement plans are made (n13)
Summary
The occurrence of care and nursing care-related errors / adverse events is closely related to the adoption of a safety culture. It is considered a key issue in clinical practice. The way healthcare errors are interpreted and acted upon maintains the understanding of punitive or hidden postures. Changing this scenario rests on the health managers’ understanding of the error as necessary. Frequently, those adverse events are related to flaws in the health system itself and its processes. Identifying the potentials and weaknesses of the health teams towards adverse events is essential, facilitating the adoption of preventive measures and trust among the professionals.[2]
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