National Patient Safety Program Research Articles

Nurses' perceptions about the patient safety climate in Primary Health Care.

to evaluate the patient safety climate in Primary Health Care from the perspective of nurses working in the services. a quantitative and cross-sectional study conducted with 148 nurses from a municipality in the state of São Paulo. The Brazilian version of the Primary Care Safety Questionnaire Survey and personal, professional, and organizational performance variables (intention to stay at work, job satisfaction, care quality, and frequency of incidents) were used. Parametric and non-parametric comparison tests and Spearman's correlation coefficient were performed, considering a 5% significance level. the safety climate was positive, varying from 4.52 to 5.33 and differing across districts for workload (p=0.0214) and leadership (p=0.0129). The safety climate professional variables and dimensions differed in relation to the frequency of incidents. Teamwork and safety and learning system were strongly correlated with job satisfaction and moderately with perceived care quality. teamwork and safety and learning system stood out for their positive correlations with job satisfaction and care quality. A positive safety climate favors the involvement of Primary Care nurses to develop improvement plans aligned with the National Patient Safety Program. (1) The safety climate is perceived differently across health districts. (2) There is a correlation between the climate dimensions and professional satisfaction. (3) Workload and leadership exert an influence on the safety climate perception. (4) There is a relationship between the safety climate and reporting of care-related incidents. (5) The safety climate is perceived differently among nurses regarding their role.

Integrating Care Coordination and Mental Health Research Into Dialysis Practice: Stakeholder Perspectives, Methods, and Outcomes

Despite many studies suggesting beneficial innovations for patients, few make it into clinical practice. This study aims to enhance patient care by facilitating effective dissemination of patient-centered outcomes research to health care workers in outpatient dialysis facilities, aided by the Patient-Centered Outcomes Research Institute's (PCORI) dissemination and implementation framework. Dissemination and implementation project. Outpatient hemodialysis facilities in the United States. We brought together panels of key stakeholders, which included researchers, patient subject matter experts, and dialysis personnel. Their role was to provide guidance on the content and methods for disseminating research findings. With a focus on 2 critical patient safety areas-care coordination or care transitions and mental or behavioral health-we developed virtual education modules. These modules were then made available to outpatient dialysis facilities by the national 5-Diamond Patient Safety Program. In 2022, the training was used by more than 2,500 dialysis facilities and approximately 40,000 dialysis staff in the care coordination module, and by more than 300 dialysis facilities and 5,000 staff for the mental health module. Cumulatively, the modules affected more than 179,000 patients. Evidence of efficacy was the significant increase in trainee knowledge of research findings and implementation considerations (P≤0.05). Potential selection bias because dialysis facilities that did not participate in the program may differ significantly from those that did, which may affect generalizability. In addition, variable timing in release of the different modules may have influenced uptake by facilities. By using key stakeholder guidance and accessible virtual education modules, the implementation framework shows promise in effectively disseminating research findings within outpatient dialysis settings. This method potentially carries implications for broader health care settings as well. Our study addresses a common health care challenge-many promising ideas for improving patient care never actually reach the patients. We aimed to bridge the dissemination gap by sharing research with health care workers in outpatient dialysis, promoting evidence-based practice. We collaborated with experts, patients, and dialysis personnel to develop easy-to-understand educational materials focused on 2 critical topics: care coordination and mental health. In 2022, our training benefited more than 2,500 facilities and 40,000 staff for care coordination, and 300 facilities with 5,000 staff for mental health, positively affecting more than 179,000 patients. We found that the training significantly increased knowledge among staff. Our approach shows promise for sharing research effectively in dialysis centers and potentially in other health care settings.

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

Improvements in Patient Safety Structures and Culture following Implementation of a National Public Program: An Observational Study in Three Brazilian Hospitals

Objective: The aim of this study was to observe and describe the changes in the structures for patient safety (PS) and PS culture (PSC) at the level of health facilities, following the implementation of the National Patient Safety Program (NPSP). Methods: An observational, longitudinal, and descriptive study including follow-up of changes in structure and activities for PS and assessments of PSC before and 15 months after the NPSP enforcement. Three Brazilian hospitals with different management logistics participated in the study (federal public, state public, and private). PSC was measured using the AHRQ’s instrument, adapted and validated for the Brazilian context (Hospital Survey on Patient Safety Culture [HSOPSC]). Changes in structure and activities to improve PS were mapped against the NPSP objectives. Changes in PSC were assessed by the hospital and discussed considering a change theory based on the literature. Results: Structural changes occurred in all hospitals but at a different pace and extension. A PS unit, adoption of some PS protocols, and training on PS occurred in the three hospitals. PSC significantly improved in all facilities. Public hospitals had the worst baseline PSC but showed greater improvements. The state hospital presented few structural changes and soon had the lowest ratings of PSC. Conclusions: This study demonstrates that external regulatory initiatives can trigger, even if unevenly, actions promoting PS and relevant internal structural changes, which in turn seem to increase awareness and improvement in PSC.

Pressure ulcer prevalence and prevention interventions - A ten-year nationwide survey in Sweden.

The aim of this study was to describe pressure ulcer prevalence and prevention interventions in hospital care in Sweden based on nationwide surveys conducted over a 10-year period. All Swedish hospitals were invited to participate in annual pressure ulcer prevalence surveys during the period 2011-2020. The data collection protocols included gender, age, skin assessment, risk assessment, and preventive interventions. In total, more than 130,000 patients were included in the ten prevalence surveys. The prevalence of pressure ulcers in Swedish hospital patients decreased significantly from 17.0 %to 11.4% between 2011 and 2020 and hospital-acquired pressure ulcers decreased from 8.1% to 6.4% between 2018 and 2020. There was no significant decline in medicaldevice-related pressure ulcers during the same period. The proportion of patients who were risk and skin assessed increased, as did the use of pressure-reducing mattresses, sliding sheets, heel protection, and nrepositioning plans. This study shows that the implementation of a national patient safety program has had an impact on the nationwide prevalence of pressure ulcers in hospital care and the occurrence of prevention strategies. However, one in ten patients in Swedish hospitals still suffers from pressure ulcers. Further improvements can be made.

Safety culture in the perception of public-hospital health professionals.

ABSTRACTOBJECTIVE Evaluating safety culture in the perception of professionals working in public hospitals of the Unified Health System (SUS) of Distrito Federal, Brazil, three years after the implementation of the National Patient Safety Program (PNSP).METHODS Analytical cross-sectional study conducted in eleven public hospitals using the Safety Attitudes Questionnaire (SAQ) in electronic format. Stratified sampling was estimated according to the proportion of the total number of professionals in each hospital, as well as the representativeness of each professional group. The results of the total score and domains equal to or greater than 75 were considered positive. Descriptive and inferential analyses of professional groups and hospitals were carried out.RESULTS 909 professionals participated. The total score by professional group was negative (62.5 to 69.5) and the domains differed statistically in all cases. The eleven hospitals had a negative total score (61.5 to 68.6). The domains to attain positive performance were job satisfaction, stress recognition and teamwork climate. The lowest results were in working conditions and management perception domains, for which none of the hospitals had an average above 75. Differences were also found for domain means across hospitals, except in management perception.DISCUSSION Three years after the implementation of PNSP, the safety culture in eleven hospitals evaluated was weak, although the domains of job satisfaction, stress recognition and teamwork climate had positive results. The results can contribute to decision-making by managers, as safety culture is an essential element in the implementation of patient safety policy.

Lessons from the Brazilian National Patient Safety Program for Building Safety Culture in Hospitals

Strong safety culture is foundational to improving patient safety. National or large-scale, multi-organizational programs combining organization-level components with targeted clinical components m...

Knowledge of the national patient safety program by health professionals at a regional hospital

To evaluate the knowledge of health professionals in a public teaching hospital about the National Patient Safety Program. Cross-sectional study, applying knowledge questionnaires from the National Patient Safety Program and Hospital Survey on Patient Safety Culture (HSOPSC). Descriptive, univariate and multivariate analyzes were performed. The study included 331 professionals, 44.0% nursing technicians / assistants, 29.7% nurses, 17.1% doctors and 10.5% other professionals. Of the 287 professionals who answered the question about the Program's knowledge, 78% said they did not know it, almost all (94.5%) were unaware of its six protocols and 90.1% did not receive training on this public policy. Nurses (OR = 15.46; 95% CI = 2.88-82.96) and professionals who held administrative positions with direct contact with the patient (OR = 55.46; 95% CI = 10.23-300.54) if highlighted the knowledge of the existence of the protocols. The degree of knowledge reported by the professionals proved to be insufficient, demonstrating a possible negligence regarding the theme by managers and educators.

How Can Implementation of a Large-Scale Patient Safety Program Strengthen Hospital Safety Culture? Lessons From a Qualitative Study of National Patient Safety Program Implementation in Two Public Hospitals in Brazil

Large-scale (e.g., national) programs could strengthen safety culture, which is foundational to patient safety, yet we know little about how to optimize this potential. In 2013, Brazil's Ministry of Health launched the National Patient Safety Program, involving hospital-level safety teams and targeted safety protocols. We conducted in-depth qualitative case studies of National Patient Safety Program implementation in two hospitals, with different readiness, to understand how program implementation affected enabling, enacting, and elaborating processes that produce and sustain safety culture. For both hospitals, external mandates were insufficient for enabling hospital-level action. Internal enabling failures (e.g., little safety-relevant senior leadership) hindered enactment (e.g., safety teams unable to institute plans). Limited enactment and weak elaboration processes (e.g., bureaucratic monitoring) failed to institutionalize protocol use and undermined safety culture. Optimizing the safety culture impact of large-scale programs requires effective multi-level enabling and capitalizing on the productive potential of interacting national- and local-level influences.

Reflexões sobre os protocolos do Programa Nacional de Segurança do Paciente em um hospital público

O Programa Nacional de Segurança do Paciente (PNSP) foi instituído no Brasil, em 2013, com o intuito de contribuir com a qualificação do cuidado em todos os estabelecimentos de saúde do território nacional. Objetivo: Descrever as reflexões sobre a implantação dos protocolos do Programa Nacional de Segurança do Paciente em um hospital público. Método: trata-se de relato de experiência, a partir de observação in loco, sobre a possibilidade de implantação dos protocolos do PNSP em um hospital público no interior da Bahia. Resultados e discussão: A implantação dos protocolos esbarra em entraves, como a falta destes protocolos na unidade, deficiências na estrutura física, aquisição e manutenção de materiais de consumo e permanentes, e inconsistência da cultura de segurança do paciente na instituição. Como fator positivo, o hospital possui o Núcleo de Segurança do Paciente, que pode elaborar os protocolos voltados à realidade local e os indicadores para monitoramento, e planejar as ações para sua implantação. Conclusão: Os protocolos são viáveis para implantação no hospital do estudo, devendo ser encorajados sua implementação e seguimento.

Reflections on patient safety incident reporting systems.

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.

Evolution of the national patient safety program: an analysis of the public data made available by the National Health Surveillance Agency

Introdução: O Programa Nacional de Segurança do Paciente (PNSP) foi instituído em 2013 no Brasil e, com ele, legislação que torna obrigatórias a constituição de núcleos de segurança do paciente (NSP) e a notificação de incidentes em estabelecimentos de saúde. Desde então, a Agência Nacional de Vigilância Sanitária (Anvisa) publica boletins contendo compilado das informações contidas nas notificações, porém não faz comparação ao longo do tempo. Objetivo: Analisar, a partir de dados públicos da Anvisa, a evolução do PNSP, em cinco anos. Método: Estudo retrospectivo, de análise documental, a partir da revisão das publicações da Anvisa denominadas Boletim de Segurança do Paciente e Qualidade em Serviços de Saúde, publicadas entre 2015 a 2019. Resultados: Houve aumento no número de NSP em 416,00%, porém representa menos de 50,00% dos estabelecimentos hospitalares brasileiros. As notificações aumentaram em mais de 900,00%, mas ainda se faz necessário qualificar as informações previamente ao envio à Anvisa. A comparação da proporção dos casos mostrou que houve discreta redução dos danos graves e óbitos, porém foram perdidas 1.491 vidas por eventos adversos na assistência à saúde no período avaliado. Estudos que avaliem o impacto de ações nacionais nos resultados do cuidado devem ser estimulados. Conclusões: Ações coordenadas de vigilância sanitária e de assistência à saúde devem ser intensificadas, a fim de tornar a segurança do paciente uma real prioridade de saúde pública no Brasil. Apesar de não haver uma política com financiamento perene de ações, nota-se que o PNSP provocou evolução positiva ao longo dos anos e que a mobilização das instituições e profissionais de saúde brasileiros tem potencial de salvar vidas.

Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture

ObjectivesOur primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was...

Profilaxia das lesões por pressão: um olhar sobre a responsabilização da equipe de enfermagem

Introdução: A segurança do paciente é um tema importante que deve ser sempre preocupação dos profissionais de saúde e uma das metas da prestação do cuidado. A prevenção das lesões por pressão (LPP) é considerada item imprescindível nesse contexto. Sendo assim, a profilaxia das LPP é compromisso ético e legal da equipe enfermagem. Método: Trata-se de estudo exploratório, descritivo e de modalidade qualiquantitativa. Foi realizado em duas instituições hospitalares, uma pública e outra privada, com 34 profissionais de enfermagem dos períodos noturno e diurno das clínicas médica e cirúrgica de ambas e da unidade de terapia intensiva. Utilizaram-se formulários com duas partes: a primeira para caracterização dos participantes; a segunda com perguntas abertas e de múltipla escolha. As respostas das perguntas abertas foram organizadas tematicamente, e os dados sociodemográficos e as respostas às perguntas de múltipla escolha foram organizados segundo a frequência. Resultados: Cerca de 45% dos técnicos e 50% dos auxiliares de enfermagem apresentam carência no conhecimento das LPP, reafirmando as noções limitadas sobre o Programa Nacional de Segurança do Paciente. Todos os enfermeiros, 73,33% dos técnicos e 37,5% dos auxiliares de enfermagem reconheceram que nem todas as medidas profiláticas são úteis nas situações de risco para as lesões, evidenciando o pouco comprometimento da equipe na aplicação integral dessas medidas. Considerações finais: A educação permanente em saúde é o meio mais eficaz a ser desenvolvido pela equipe de enfermagem, estimulando atuação crítica, reflexiva, propositiva, compromissada e tecnicamente eficiente, o que auxilia na efetivação das medidas de segurança do paciente.

The Protagonism of the Brazilian Health Regulatory System in the Evolution of Patient Safety in the Country: History, Dilemmas, and Current Challenges.

This article aims to identify and analyze the legal and regulatory frameworks with an interface with patient safety, considering the historical path of the patient safety policy in Brazil. This is a historical review based on the relevant literature to the topic such as papers, legislation, and official documents with an interface with public health policies from 1988 to 2019. We also performed a documentary search to include data from the Brazilian Health Regulatory Agency (ANVISA) such as normative and nonnormative regulatory instruments. After organizing the data, the process of content analysis was performed. We debated initially the historical aspects of sanitary surveillance of health services in addition to main actions taken by the Brazilian Health Regulatory System, which includes sanitary regulation and patient safety challenges. We identified a diversity of regulations published by ANVISA in the past decade related to patient safety, in addiction to sanitary actions. These initiatives culminated in the establishment of the National Patient Safety Program in 2013, followed by other health improvements, such as surveillance, incidents monitoring, and safe practices self-assessment. The regulation and sanitary actions directed to patient safety in Brazil have increased after the creation of ANVISA. In the face of this activities, the social role played by the Brazilian Health Regulatory System toward the advancement in the field of risk minimization in health services can be highlighted as a protagonist in the process of promoting patient safety.

Practice challenges in patient safety

to understand the professional practice challenges in reaching the goals and objectives of the National Patient Safety Program (Programa Nacional de Segurança do Paciente). qualitative case study, based on the Comprehensive Sociology, carried out with 31 professionals from the Patient Safety Center (Núcleo de Segurança do Paciente) and the nursing team, working in a teaching hospital. Data collection took place between May and December 2015 through interviews, observation and documentary analysis. The analysis proceeded according to the prerogatives of the Content Analysis. three categories emerged: the prescribed reality; material resources and their impact on care; and human resources related to the reality. challenges to safe professional practice are caused by inadequate physical structure, insufficient physical and human resources, but mainly invade the transition from the prescriptive reality scope.

>Metodologias ativas para a cultura de segurança

Introduction: The promotion of the patient safety culture makes part of the strategies proposed in the National Patient Safety Program. Objective: This paper presented the experience of the Patient Safety Nucleus during 2018 in promoting the patient safety culture. Method: The use of active learning methodologies in a medium-sized public hospital in Minas Gerais, that belongs to the Sentinel Network of Anvisa. Results: The “10 Goals – Patient Safety” campaign originated after the identification and prioritization of the macroproblems related to patient safety in the institution. The 10 goals defined were: 1) Effective communication; 2) Fall prevention; 3) Safe surgery; 4) Prevention of pressure injury; 5) Safe use of probes and catheters; 6) Safe identification; 7) Drug safety; 8) Clean and safe care; 9) Patient involved; and 10) Safe and rational use of blood. The structuring of educational strategies was based on active learning and problematization methodologies. Conclusions: It was observed that the use of active methodologies can stimulate and induce employees and users to discuss and know the meaning of the hospital safety culture.

O programa nacional de segurança do paciente e as implicações nos serviços de saúde como aspecto relevante ao desenvolvimento regional

O presente estudo tem como objetivo refletir sobre o Programa Nacional de Segurança do Paciente e as implicações nos serviços de saúde como aspecto relevante ao desenvolvimento regional. Deste modo, ressalta a necessidade da implementação de ações que contribuam para a melhoria dos serviços e para a efetivação do acesso à saúde ao considerar que receber assistência à saúde é um direito de todos e dever do Estado. O profissional não possui o intuito de causar qualquer dano na assistência prestada, pois tem como objetivo principal o cuidado, porém, mesmo de forma não intencional ainda há ocorrência de eventos adversos relacionados à assistência à saúde. Diante disso, o Programa Nacional de Segurança do Paciente se torna ferramenta indispensável para incentivar o desenvolvimento de medidas preventivas para que os serviços tornem o sistema mais seguro. Na coleta de dados exploraram-se documentos da Secretaria Estadual de Saúde de Santa Catarina, relatórios da Vigilância Sanitária Estadual e estudos realizados acerca da temática, no Planalto Norte Catarinense. Os dados evidenciaram as iniciativas que se concretizaram ou estão em consolidação sob influência de aspectos históricos, políticos e culturais de cada município e a existência ou não de um Núcleo de Segurança do Paciente atuante.
 Palavras-chave: Desenvolvimento Regional. Saúde. Segurança do Paciente.

Conhecimento dos Profissionais de Enfermagem sobre Segurança do Paciente Oncológico em Quimioterapia

Introdução: A segurança do paciente vem adquirindo grande importância em níveis nacional e internacional, especialmente na oncologia, na qual há uma preocupação crescente com os erros/eventos adversos relacionados às drogas quimioterápicas antineoplásicas, tendo como principal premissa a qualidade do cuidado em saúde e a assistência segura. Objetivo: Avaliar o conhecimento dos profissionais de enfermagem quanto à segurança do paciente oncológico em tratamento quimioterápico. Método: Estudo qualitativo, realizado no ambulatório de uma Unidade de Assistência de Alta Complexidade em Oncologia, localizado no Estado do Pará. Os dados foram coletados mediante aplicação de questionário a 11 profissionais de enfermagem e de observação nãoparticipante, analisados segundo a Análise de Conteúdo de Bardin. Resultados: Identificaram-se quatro categorias de conteúdo: (1) o conhecimento da equipe sobre as etapas do tratamento quimioterápico e percepções gerais acerca da segurança dos pacientes; (2) higienização das mãos e risco de queda; (3) inexatidão na identificação do paciente e na comunicação eficaz; e (4) administração segura de quimioterapia antineoplásica. Nessas categorias,foi possível constatar falhas de conhecimento nas etapas do tratamento e administração segura de quimioterapia antineoplásica, na identificação do paciente e na comunicação eficaz. Observou-se o empenho dos profissionais do serviço em implementar o Programa Nacional de Segurança do Paciente (PNSP) com a identificação dos pacientes com crachá, prescrições impressas e protocolos de extravasamento e derramamento. Entretanto, a adesão a higienização das mãos não foi observada. Conclusão: Inferiu-se a necessidade de educação permanente e continuada dos profissionais, apesar da existência de itens assistenciais que atendem aos protocolos do PNSP.