Reflections on patient safety incident reporting systems

Author:

Harada Maria de Jesus Castro Sousa1ORCID,Silva Ana Elisa Bauer de Camargo2ORCID,Feldman Liliane Bauer1ORCID,Tavares Sheilla Siedler3ORCID,Gerhardt Luiza Maria4ORCID,Lima Júnior Antônio José de4ORCID,Kolankiewicz Adriane Cristina Bernat5ORCID

Affiliation:

1. Universidade Federal de São Paulo, Brazil

2. Universidade Federal de Goiás, Brazil

3. Universidade de Sorocaba, Brazil

4. Rede Brazileira de Enfermagem e Segurança do Paciente Nacional, Brazil

5. Universidade Regional do Noroeste do Estado do Rio Grande do Sul, Brazil

Abstract

ABSTRACT Objective: 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. Method: 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. Results: 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. Final Considerations: 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.

Publisher

FapUNIFESP (SciELO)

Subject

General Nursing

Reference13 articles.

1. Minimal Information Model for Patient Safety Incident Reporting and Learning Systems,2014

2. To err is human: building a safer health system;Kohn LT,2000

3. Patient Safety Learning Systems: a systematic review and qualitative synthesis;Ont Health Technol Aval Serv,2017

4. Portaria nº 529, de 1º de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP),2013

5. Agência Nacional de Vigilância Sanitária (Anvisa). Resolução da Diretoria Colegiada Nº 36, de 25 de julho de 2013,2013

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