Navegando por Palavras-chave "Notificação De Incidentes"

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    Segurança do paciente na atenção primária à saúde: análise de incidentes near miss em unidades de Estratégia de Saúde da Família
    (Universidade Federal de São Paulo (UNIFESP), 2019-05-30) Amaro, Meire Augusta Celestino [UNIFESP]; Bohomol, Elena [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Objectives: To analyze the reported near miss incidents in primary health care. Methods: This is a documental, retrospective, descriptive research of quantitative nature. The study analyzed the reported incidents reports to a database, with reports of 13 Basic Health Units with Family Health Strategy in the city of São Paulo, from 2014 to 2016. For the analysis of the types of incidents notified, the Chi-square Test was used with a confidence interval of 95%. The categorization of incidents was based on the International Classification for Patient Safety, proposed by the World Health Organization. The Kappa Test was used to evaluate the level of agreement between the evaluators. The Research Ethics Committee of the Municipal Health Secretariat of São Paulo approved the study. Results: Two evaluators performed a reading and classification of 3204 incident notifications independently, presenting Kappa between 0.36 and 0.42, indicating low concordance. The convergences value between the first two evaluators was 1759 (55%) of the total notifications analyzed, after the inclusion of the third evaluator, the convergences value was 2344 (73%). 1093 near miss were identified, the most frequent types were: medications, 687 (62.8%), with prescription problems, 629 (92%), documentation, 312 (28.5%), errors with requests 128 (41%), problems with medical records, 67 (21%); clinical administration 66 (6%), the admission errors of the patient, 17 (26%), scheduling errors, 14 (21%) and routing errors 11 (17%). Conclusions: The most frequently reported near miss incidents were medication, highlighting prescribing errors, documentation pointing to errors with requests and medical records. Incidents of clinical administration, however, lead to patient admission errors, scheduling errors, and referral errors.