Construção coletiva de protocolo para instrução de notificação de incidentes relacionados ao cuidado em saúde por profissionais assistenciais

Abstract

Patient Safety achieved its benchmark in 1999, when the document To Err Is Human was published, which contained alarming data on adverse events occurring in hospitals in the United States due to errors related to healthcare. In Brazil, Ordinance No. 529 was created, dated April 1, 2013, which established the National Patient Safety Program (PNSP) in order to contribute to the qualification of health care in all health establishments in the national territory. Through this Ordinance, the Patient Safety Culture can be characterized in five operationalized characteristics, among them, the culture that encourages and rewards safety-related notification and the culture that, upon the occurrence of incidents, promotes organizational learning. However, given this context, it is necessary for errors to be reported, described and notified, so that the cause of the problem is known and intervention is carried out on an educational, preventive and non-punitive basis, since the record serves as an instrument of communication and discussion. between management and assistance. From this perspective, adherence to the reporting of incidents related to healthcare by healthcare professionals has been an important element in producing actions to improve Patient Safety. Thus, this research had the general objectives of analyzing adherence to reporting incidents related to healthcare by healthcare professionals in a teaching hospital and developing an institutional protocol to instruct health professionals on the correct reporting of incidents in a teaching hospital. This is a Convergent Care Research (PCA) with a qualitative approach, carried out at the Onofre Lopes University Hospital, located in the city of Natal/RN, from May to December 2023. Data collection was carried out in two stages: the first consisted of the application of semi-structured interviews, which made it possible to identify knowledge and practices for reporting incidents related to health care, with the participation of 32 professionals. In the second stage, two convergence group meetings were held, which included discussion of interview data and the construction of the institutional protocol, with the participation of 14 professionals in the first meeting and 12 in the second. The analysis of the data produced in the two stages was carried out following the proposals in the PCA. To organize and process the data, the Atlas Ti software was used. Ethical principles were respected. The results obtained made it possible to identify the main barriers and strategies for reporting health-related incidents. It was highlighted that the lack of adequate information and the lack of knowledge of the VIGIHOSP instrument and the importance of notification influence professionals not carrying out this procedure, resulting in underreporting. The study enabled the creation of an innovative protocoltype tool, since, in the studied institution and in the EBSERH network, there is no specific protocol to guide professionals in reporting incidents at VIGIHOSP. This advance is essential to foster a culture of patient safety and improve adverse event management processes.