Reflections on patient safety incident reporting systems.

Maria De Jesus Castro Sousa Harada,Adriane Cristina Bernat Kolankiewicz,Sheilla Siedler Tavares,Luiza Maria Gerhardt,Liliane Bauer Feldman,Antônio José De Lima Júnior,Ana Elisa Bauer De Camargo Silva

doi:10.1590/0034-7167-2020-0307

Abstract

To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population's participation in reporting, and point out challenges in the Brazilian system. Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added. Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature. In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, and institutions. To simplify data entry by improving the interface and importing data from the reporting system is an objective to be achieved.

Highlights

Health care incidents happen with unacceptable frequency and affect patients who seek health services to prevent, diagnose, treat, or rehabilitate themselves
20 years after the publication of the report To Err is Human: Building a Safer Health Care System, which revealed the weaknesses of health services in the United States of America (USA), many actions and campaigns were developed and implemented, in several countries, in favor of patient safety (PS)
To reflect on the main characteristics and recommendations of Incident Reporting Systems (IRSs), discuss the population’s participation in the reporting, and point out challenges in the Brazilian reporting system. This is a reflection study, built on the basis of Ordinance No 529, of April 1, 2013, from the Ministry of Health, which instituted the Programa Nacional de Segurança do Paciente (PNSP) and considered the priority of PS in health services on the political agenda of the WHO Member States, of which Brazil is a part(4). This reflection was based on Collegiate Board Resolution (CBR) no 36, of July 25, 2013, which instituted, among other actions, that of surveillance, monitoring, and notification of adverse events (AEs) by health services, through the electronic tools provided by Agência Nacional de Vigilância Sanitária (Anvisa), constituting an online reporting system, with a guaranteed return to the reporting units(5)

Summary

Introduction

Health care incidents happen with unacceptable frequency and affect patients who seek health services to prevent, diagnose, treat, or rehabilitate themselves. The national IRS enables reporting done by citizens, health professionals, and by the Núcleos de Segurança do Paciente (NSPs) [Patient Safety Centers], a health service instance created to promote and support the implementation of actions aimed at PS.

Results

Conclusion