Bakgrund:Inom hälso-och sjukvården är de flesta patientsäkerhetsriskernaorsakadeav denmänskliga faktorn och bristande kommunikation. CrisisResourceManagement (CRM) är en relativt vedertagen metod inom sjukvården och en metod som landstingen satsat på under de senaste åren. Inom flygindustrin förespråkas denna metod och ökadforskning har också gjorts på metoden inom akutsjukvården. Målet är att uppnå ökad patientsäkerhet. Syfte:Att beskrivaanestesisjuksköterskors erfarenheter av CrisisResourseManagement inom Västerbottens LänsLandsting med fokus på kommunikation.Metod:En kvalitativ semistrukturerad intervjustudiemed niostycken anestesisjuksköterskor från Västerbottens läns landsting. De intervjuadesunder 15-25 minuter utifrånen semistrukturerad intervjumall utvecklad av författarna. Urval skedde utifrån tillgänglighetsprincipen på akut-och operationscentrum. Innehållsanalys användes för att skapa subkategorier, kategorier och tema.Resultat:Anestesisjuksköterskorna hade svårt att definiera begreppet CRM men hade en uppfattning av att metoden handlade om kommunikation. Vidare visade analysen att CRM används impliciti akutsituationer och verkar varapersonbundet. Den vanligaste formen av kunskapsinhämtning avCRM var i form av praktiska övningar inom landstinget.Anestesisjuksköterskorna beskrev önskvärt ledarskap och förespråkade struktur i teamarbetetoch kommunikationen. CRM framställdes som en välkommen metod som kan bidra med ökad trygghet och patientsäkerhet. Studien resulterade i kategorin att arbeta i fungerande team, med subkategorierna kunskap, ledarskap och struktur. Dessakategorier och subkategorier genomsyrade och bildadetemat trygghet.Slutsats:Författarnarekommenderar utbildning och kontinuerligövning för att möjliggöraimplementering av CRM i verksamhetenmed möjlighet attöka patientsäkerheten. Eftersom sjukvården idag ärbegränsad av ekonomioch personalbristlyfter författarna förslag till enklare och billigare utbildningsmetoder såsomnätbaserad teoriutbildning senare följt av övningstillfällen.

Atualmente, é uma preocupação a exposição dos pacientes de unidade de terapia intensiva (UTI) a situações da prática clínica que colocam suas vidas em risco. Um agravante para essa exposição são os múltiplos agentes farmacológicos que esses pacientes recebem, aliado ao seu desequilíbrio fisiológico. Entre os principais problemas relacionados à utilização de medicamentos na UTI, estão as interações medicamentosas (IM), que quando não prevenidas ou tratadas prontamente podem provocar danos irreparáveis no paciente. Considerando que o conhecimento sobre IM é uma importante ferramenta para otimização no cuidado em enfermagem, desenvolveu-se este estudo com o propósito de analisar o conhecimento sobre interações medicamentosas de enfermeiros que atuam em unidades de terapia intensiva de adultos de três hospitais públicos de Goiânia - GO. Trata-se de um estudo descritivo, não experimental, com delineamento transversal. A população foi composta por 64 profissionais e a amostra constituiu-se de 51 enfermeiros que aceitaram participar do estudo. Para a coleta de dados construiu-se um instrumento com perguntas de múltipla escolha sobre IM. As alternativas desse instrumento foram extraídas da base de dados do MICROMEDEX® Healthcare Series (1974- 2009). Os dados foram organizados e analisados usando Microsoft Excel 2002. A faixa etária dos enfermeiros variou de 25 a 55 anos, com média de 38,9 anos. O tempo de atuação na enfermagem variou entre 2 e 31 anos, com média de 12 anos. Sobre a formação em farmacologia, 29 (56,9%) enfermeiros informaram ter tido uma formação regular na graduação e 49 (96,1%) expressaram necessidade de capacitação em farmacologia. Quanto ao conhecimento sobre interações medicamentosas na UTI, houve uma relação de acertos e erros praticamente de 50%. Os itens que alcançaram maior número de respostas corretas foram os que abordaram as interações relativas a medicamentos com ação sedativa e analgésica como o caso da dupla fentanila + morfina (86,3%). Os itens que apresentaram maior número de respostas incorretas foram os que abordaram medicamentos de ação antiinfecciosa e anti-hipertensiva. Quanto ao conhecimento do manejo clínico sobre IM, observou-se que metade dos profissionais responderam corretamente em mais de 50% dos itens se destacando, também, os medicamentos de ação sedativa e analgésica. Os resultados evidenciaram a necessidade de melhorar as práticas de cuidados na utilização de medicamentos e chamam a atenção para a importância de atualização dos enfermeiros a respeito dos medicamentos comumente administrados na UTI. Por sua vez, é necessário fornecer apoio aos profissionais para que busquem conhecimentos que sustente a qualidade da prática. Espera-se que as universidades e demais instituições de saúde se sensibilizem quanto à necessidade de difundir e promover um conhecimento farmacológico, adequado aos profissionais de enfermagem tendo em vista que a segurança do paciente na terapia medicamentosa deve ser uma prioridade no contexto da saúde. / Nowadays there is a hard concern on the exposition of intensive care unit (ICU) patients to situations on clinical practice which can put their lives in risk. An aggravating factor for this exhibition is the multiple pharmacological given to these patients, allied to their physiologic disturbs. Among the main troubles related to using drugs in ICU shot out drug interactions (DI). When not prevented or promptly treated, they can cause irreparable damage to the patients. As the knowledge on DI is an important tool for nurse optimizing care, this study was done aiming to analyze information which nurses have on DI in adult ICU in three public hospitals in Goiania- GO, Brazil. It is a descriptive not experimental cross-sectional study. Population was formed by 64 professionals and the sample had 51 nurses who agreed to participate on it. Data collection used an instrument with multiple choice questions on DI. The instrument alternatives were picked up on MICROMEDEX® Healthcare Series (1974- 2009) database. These data were organized and analyzed by Microsoft Excel 2002. The participants ages ranged from 25 to 55 years, mean 38.9 years. The nursing working time ranged from 2 to 31 years, mean 12 years. Concerning to formation in pharmacology, 29 (56,9%) of the nurses informed that they had a regular formation on Graduation Course and 49 (96,1%) expressed need for training in pharmacology. There was a ratio of hits and misses nearly 50% on ICU DI. The items that reached most correct answers were those related to interactions due to sedative and analgesic drugs, as the pair fentanil + morphine (86,3%). Questions that showed most incorrect answers were related to anti infection and anti hypertension drugs. Concerning to clinical manage on DI, 50% of the professionals answered correctly more than 50% of the questions. Sedative and analgesic drugs stood out. The results showed the need of improving care practices on using drugs and they claim attention to the importance of training nurses on drugs commonly administrated on ICU. It is also necessary to support the professionals in order they can look for knowledge that give quality on the practice. One hopes that the universities and other institutions may be touched by the need of spreading and improving a nurse pharmacological knowledge aiming the patient insurance on drug therapy as a priority in health context.

Comumente, o cuidado ao paciente é prestado de forma bem-sucedida, no entanto, por mais preparada e capacitada que uma equipe de trabalho esteja, erros poderão acontecer. O gerenciamento de riscos cria alternativas para diminuir ou eliminar as falhas, que podem ocorrer durante a prática dos profissionais, e os enfermeiros desempenham papel de destaque nesse gerenciamento, pois exercem variadas funções dentro das instituições de saúde sendo os responsáveis pelo cuidado durante as 24 horas. O objetivo deste estudo foi analisar o gerenciamento da segurança do paciente junto aos Serviços de Enfermagem de hospitais do interior do Estado de São Paulo, por meio de pesquisa com os enfermeiros responsáveis técnicos e enfermeiros coordenadores das áreas assistenciais e apoio. Trata-se de estudo descritivo, não experimental, com delineamento transversal. Para coleta dos dados, foram elaborados dois instrumentos com questões de múltipla escolha, utilizando-se como base o questionário da Agency for Healthcare Research and Quality (AHRQ). Os dados foram organizados e analisados por meio de estatística descritiva, utilizando-se o software SPSS. O estudo foi realizado em 7 hospitais, com 56 sujeitos sendo, 7 responsáveis técnicos e 49 coordenadores. O tempo de formação profissional, para 100% dos responsáveis técnicos ficou acima de 9 anos e dos coordenadores variou de 2 a mais de 14 anos. Dentre os pesquisados, 85,7% dos responsáveis técnicos e 79,6% dos coordenadores referiram possuir cursos de pós- graduação. O estudo revelou que 100% dos hospitais pesquisados possuem sistema de notificação de eventos adversos, 71,4% possuem comissão de gerenciamento de riscos implantada. Dentre os coordenadores, 87,7% relataram que notificam quando o erro atinge o paciente, 81,7% notificam quando o erro tem potencial para prejudicar o paciente e 49% notificam quando se trata de um quase erro. Destaca-se que 12,3% coordenadores referiram relatar às vezes, raramente ou não relatam, mesmo que o erro atinja o paciente. Dentre os eventos adversos mais comumente notificados destacam-se os erros com medicações, perdas de cateteres, quedas, flebites e úlceras por pressão. Nos últimos 12 meses, 38,7% dos coordenadores referiram que realizaram entre 1 a 5 notificações. Outro ponto destacado por 89,8% dos coordenadores é o medo que os funcionários sentem que os erros sejam inscritos em suas fichas funcionais. Quanto às condutas com os eventos adversos notificados, 100% dos responsáveis técnicos referiram discutir os casos e capacitar as equipes. Em relação ao apoio da administração para implantação de medidas de segurança no hospital, a concordância entre os responsáveis técnicos foi de 100% e 93,9% dentre os coordenadores, mesmo assim, 85,7% dos responsáveis técnicos classificaram a segurança da assistência prestada aos pacientes no hospital como aceitável, diferentemente de 73,5% coordenadores que consideraram excelente ou muito boa. Os resultados evidenciaram a necessidade de desenvolver em todas as instituições uma cultura institucional não punitiva diante da ocorrência de eventos adversos, definição de políticas claras focadas na segurança do paciente, fortalecimento das comissões de gerenciamento de riscos, incentivo às notificações dos eventos adversos e análise das causas-raiz para que mudanças e barreiras consistentes nos processos possam garantir resultados assistenciais com melhor qualidade. / Patient care delivery tends to be successful but, no matter how prepared and trained a team is, errors can happen. Risk management creates alternatives to reduce or eliminate mistakes, which can take place in professional practice, and nurses play a paramount role in this management, as they have different functions in health institutions and are responsible for 24-hour care. The aim in this study was to analyze patient safety management in hospital nursing services in the interior of São Paulo State, Brazil, through a study that involved the nurses who acted as technical managers and as care and support coordinators. A descriptive and non-experimental study with a cross-sectional design was carried out. To collect the data, two instruments with multiple-choice questions were elaborated, based on the questionnaire of the Agency for Healthcare Research and Quality (AHRQ). Data were organized and analyzed with the help of descriptive statistics, using SPSS software. The study was undertaken at seven hospitals, involving 56 subjects: 7 technical managers and 49 coordinators. As regards the time since graduation, 100% of the technical managers had graduated more than nine years earlier, while that of the coordinators ranged between two and more than 14 years. Among the subjects, 85.7% of the technical managers and 79.6% of the coordinators indicated a graduate degree. The study revealed that 100% of the research hospitals have an adverse event notification system and 71.4% an active risk management commission. Among the coordinators, 87.7% indicated notification when the error reaches the patient, 81.7% when the error can harm the patient and 49% in case of a quasi-error. It is highlighted that 12.3% of the coordinators indicated that they sometimes, hardly or never notify, even when the error affects the patient. The most commonly notified adverse events include medication errors, catheter losses, falls, phlebitis and pressure ulcers. In the previous 12 months, 38.7% of the coordinators indicated between one and five notifications. Another point 89.8% of the coordinators highlighted is the employees\' fear that the errors will be registered in their employee files. Concerning conducts towards adverse event notifications, 100% of the technical managers indicate they discuss the cases and train the teams. With regard to management support to put in practice safety measures at the hospital, agreement levels amounted to 100% among the technical managers and 93.3% among the coordinators. Nevertheless, 85.7% of the technical managers classified the safety of patient care in the hospital as acceptable, while 73.5% of the coordinators found it excellent or very good. The results evidenced the need, at all institutions, to develop a non-punitive institutional culture towards the occurrence of adverse events, to define clear patient safety policy, strengthen risk management commissions, encourage adverse event notifications and analyze the root causes, so that consistent changes and barriers in processes can guarantee better-quality care results.

A segurança do paciente e a cultura de segurança das instituições são atributos prioritários da qualidade dos sistemas de saúde. Na área obstétrica devido aos elevados índices de mortes maternas e neonatais, há necessidade de problematizar a Segurança do Paciente na assistência ao parto e nascimento a partir do olhar dos profissionais, com uma visão de melhoria e qualidade do cuidado. Neste contexto, o objetivo geral do estudo é analisar a percepção dos profissionais de saúde sobre a segurança do paciente no processo assistencial ao parto e nascimento. À luz do referencial de Segurança do Paciente, desenvolveu-se um estudo descritivo-exploratório e analítico com abordagem qualitativa. O cenário de estudo foi o Serviço Materno-Infantil do Hospital de Clínicas de Porto Alegre. Os dados foram coletados entre agosto e novembro de 2016, por meio de seis encontros de grupos focais, com um total de 12 profissionais da saúde participantes, entre médicos, enfermeiros e técnicos de enfermagem das unidades: centro obstétrico e internação obstétrica. Utilizou-se a Análise de Conteúdo do tipo Temática para tratamento dos dados. A pesquisa tramitou na Plataforma Brasil, obteve aprovação do Comitê de ética em Pesquisa, mediante CAAE: 57781016.1.0000.5327. Os resultados e discussões foram organizados e agrupados em três temas principais. O primeiro, “A Cultura de Segurança do Paciente no Processo de Parto e Nascimento”, desvela algumas especificidades de cada dimensão da cultura de segurança que merecem um olhar mais atento e indica a existência de uma cultura de segurança em construção. No segundo tema denominado “Promoção da Segurança do Paciente em Obstetrícia: das Metas Internacionais às Fragilidades no Cuidado”, identificou-se que a maioria das metas já foram implementadas pelo serviço e são parte integrante do processo assistencial na área obstétrica, entretanto, foram indicadas algumas fragilidades do processo, como possibilidade de melhorias. O terceiro tema, “Fortalecimento da Cultura de Segurança na Área Obstétrica”, aborda recomendações positivas para a melhoria da segurança do paciente, tais como: estratégias para redução das interrupções no serviço; ações de investigação e engajamento da administração geral; estratégia para a horizontalidade da gestão e maior envolvimento de todos os profissionais; estratégias a partir do processo de formação com o uso de simulação clínica; a acreditação hospitalar como um gatilho importante, promotor de mudanças; estratégias para o fortalecimento das orientações; sugestões para os mecanismos e materiais de identificação; o uso de tecnologias de informação na saúde para processos mais seguros; ações práticas na assistência ao transporte intra-hospitalar; estratégia de comunicação na transferência das pacientes; desconstrução de hierarquia para a comunicação efetiva; instrumentos para denunciar abusos nas relações profissionais; o estimulo ao trabalho multiprofissional e multidisciplinar; valores de satisfação dos profissionais; e o uso da técnica de grupos focais como estratégia para a sensibilização e o fortalecimento de uma cultura de segurança do paciente. Conclui-se que na percepção dos profissionais de saúde, é necessário investimento individual, coletivo e institucional com a implementação de estratégias de sensibilização e ações práticas para a efetivação da cultura de segurança e da segurança do paciente no processo assistencial ao parto e nascimento na instituição. / Patient safety and the safety culture of institutions are priority attributes to the quality of health systems. In the obstetric area due to the high rates of maternal and neonatal deaths, there is a need to problematize patient safety in the delivery assistance and delivery care from the perspective of professionals with a vision of improvement and quality for the service. In this context, the general objective of the study is to analyze the perception of health professionals about patient safety in the care process at birth and delivery. In the light of the Patient Safety referral, an exploratory and analytical descriptive study with a qualitative approach was developed. The study scenario was the Maternal-Infant Service of the Hospital de Clínicas de Porto Alegre. Data collected between August and November of 2016, through six focus group meetings, with 12 participating health professionals, among doctors, nurses and nursing technicians from the units of the Obstetric Center and Obstetric Internment. Thematic content analysis used to evaluate the data. The research carried out in Plataforma Brasil, obtained approval through CAAE: 57781016.1.0000.5327. The results and discussions were organized and grouped into three main themes. The first, “The Culture of Patient Safety in the process of delivery and birth”, which reveals some specificities of each dimension about safety culture that deserve a closer look and indicates the existence of a safety culture under construction, which requires of much institutional and individual investment, through the implementation of awareness strategies and practical actions for a major envelopment. In the second theme entitled “Promotion of Patient Safety in obstetrics: from the International Goals the fragilities in Care”, along those was identified that most of the goals have already been assimilated by the service and are an integral part of the care process in the obstetric area, however they were pointed out also some weaknesses of the process, as a possibility of improvement. The third theme, “Strengthening of Safety Culture in the obstetric area”, approach positive recommendations to the improving of Patient Safety, such as: reduction strategies of disruption; research actions and engagement of the general administration; strategy for horizontality of management and greater involvement of all professionals. strategies from the training process with the use of clinical simulation; hospital accreditation as an important trigger, change promoter; strategies to the strengthening of guidelines; Suggestions for identification mechanisms and materials; the use of health information technologies for safer processes; practical actions in in-hospital transport assistance; communication strategy in patient transference; breakdown of hierarchy for effective communication; instruments to denounce abuse in professional relations; the stimulation of multiprofessional and multidisciplinary work; values of professional satisfaction and, finally, we suggest the use of focal group technique as a strategy to raise awareness and strengthen a culture of patient safety. Concluded that in the perception of the health professionals, it is still necessary investment for the effectiveness of safety culture and patient safety in the care process at delivery and birth of the institution.

Orientador: Silvana Andrea Molina Lima / Resumo: A cultura de segurança pode ser definida como padrões de comportamento de indivíduos e/ou grupos, baseando-se em valores e atitudes, e que podem determinar a maneira como exercerão seu trabalho. Uma cultura de segurança positiva estabelece uma boa comunicação institucional e um compartilhamento eficaz da percepção sobre a importância da segurança e da confiança nas medidas preventivas adotadas. O presente trabalho teve como objetivo analisar a cultura de segurança do paciente sob a perspectiva dos enfermeiros de um hospital terciário do interior do estado de São Paulo. Trata-se de estudo quantitativo, transversal e descritivo. Foi aplicado o instrumento Hospital Survey on Patient Safety Culture (HSOPSC), validado e traduzido para o português pela ENSP – Fiocruz. A coleta dos dados foi realizada no período de agosto de 2017 a fevereiro de 2018. Após análise dos dados, verificou-se que a população é predominantemente do sexo feminino, e com idade média de 34,19 ± 6.29 anos. A maioria dos enfermeiros tem carga horária de trabalho entre 40 a 59 horas, um tempo de trabalho no hospital e na unidade menor de 5 anos. Em relação as dimensões do questionário sobre a cultura de segurança do paciente, foram avaliadas no geral, de forma positiva. Apenas a dimensão “Quadro de Funcionários” e “Percepção geral de segurança do paciente” foi avaliada de maneira negativa. A instituição possui uma cultura de segurança, uma vez que os profissionais enfermeiros realizam as notificações de ocorrênc... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Safety culture can be defined as a behavioral pattern of individuals and groups, based on their values and attitudes, and that determine the way in which they carry out their work. A safety culture is positive in relation to safety and an effective control of safety in safety and security in the preventive measures adopted. The present study had the objective of analyzing the patient 's culture from the perspective of the nurses of a tertiary hospital in the interior of the state of. This is a quantitative, cross-sectional study. The instrument Hospital Research on Patient Safety Culture, validated and translated into Portuguese by National public health school - Fiocruz, was applied. Data collection was performed from August 2017 to February 2018. After data analysis, the population was predominantly female, with a daily average of 34.19 ± 6.29 years. Most professionals have a working time between 40 and 59 hours. Regarding the dimensions of the filter on the safety culture of the patient, they were evaluated in general, in a positive way. Only one "Employee Scale" and "General Perception of Patient Safety" dimension was evaluated negatively. The institution has a safety culture, since nursing professionals perform events of adverse events such as the existence of an error and the incident without harm. The implementation, evaluation of results, investments in the systematic of errors and professional suitability can strengthen the security in the institution. It is conclude... (Complete abstract click electronic access below) / Mestre

The provision of ultra-safe healthcare relies upon investment in robust systems of work. The transition of care between healthcare providers has been shown to contribute significant risk to patients, so much so that the improvement in handover was listed as one of the top five priorities for the World Health Organisation in 2014. Current handover practices have been evaluated in medicine using numerous techniques on the qualitative – quantitative continuum. The systematic evaluation of published literature revealed a paucity of evidence in relation to the optimal transfer of patient care. As a consequence, the post-operative handover was evaluated by first undertaking semi-structured interviews of anaesthetic, recovery and surgical staff. Differences of opinion were discovered between professional groups involved in the post-operative handover. These differences have the potential to fuel inter-professional conflict. The handover process was seen as being vulnerable to the effects of outside agencies, with time pressure being most to blame. The post-operative handover was observed and a novel handover intervention was introduced, with the primary objective of reducing multi-tasking and improving information accuracy. The intervention combined education of handover error alongside standardisation of the process. The introduction of a bed-side aide memoire to separate the transfer of equipment from standardised information transfer was introduced with staff involvement. Prior to the introduction of the handover intervention, core information points such as the patient’s name and allergies were frequently omitted and the process was often beset with distraction from concomitant activities. Both of these factors improved following the introduction of the intervention. These findings support previous revelations in handover that transitions are frequently not optimised to reduce risk in the patient pathway. However, it is feasible to ameliorate this risk by introducing a low cost quality improvement intervention which aims to standardise what can otherwise be haphazard working practice.

Effective teamwork has been shown to optimize patient safety. However, teamwork research in Emergency Medical Services (EMS) is sparse. Before successful interventions can be implemented, the appropriate content of such interventions should be determined. We tested the applicability of a teamwork processes framework in emergency care (Fernandez et al., 2008) to the EMS context. We recruited participants from an EMS agency in Houston, TX, using purposive sampling. Full-time employees with a valid EMT/paramedic license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Structural coding was based on our theoretical model. Through a deliberative process, we combined codes into candidate themes. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined, and compared against our framework. We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. Our analysis identified the team processes in the Marks’ Teamwork Process Model in four domains: Action, Planning, Reflection and Interpersonal Processes. Additionally, the concepts cited as being central to team effectiveness in EMS were: leadership, crew familiarity, team cohesion, interpersonal trust, shared mental models, and procedural knowledge. The revised model was useful for describing teamwork processes that providers employ to drive performance in EMS. Additionally, we identified emergent concepts that influence teamwork processes in EMS. Our findings inform our understanding of teamwork processes in EMS, and may be useful in guiding future team-based interventions tailored to EMS. / 2019-11-08T00:00:00Z

Purpose: There is a pressing need to enhance patient safety in the hospital environment. While there are many initiatives that focus on improving patient safety, few have studied engaging patients themselves to participate in patient safety efforts. This work was motived by the belief that patients can contribute valuable information to their care and when equipped with the right tools, can play a role in improving medication safety in the hospital. Methods: This research had three aims and used a mixed-methods approach to better understand the concept of engaging patients to improve medication safety. In order to gain insight into whether patients could beneficially contribute to the safety of their hospital care, my first aim was to understand current perspectives on the sharing of clinical information with patients while they were in the hospital. To accomplish this aim, I conducted surveys with clinicians and enrolled patients in a short field study in which they received full access to their clinical chart. In Aim 2, I conducted a study to establish that the Patient Activation Measure (PAM), a common measure of patient engagement in the outpatient setting, showed reliability and validity in the inpatient setting. Building on the knowledge from Aim 1 and using the PAM instrument from Aim 2, my third aim evaluated the impact of providing patients with access to a medication review tool while they were preparing to be admitted to the hospital. Aim 3 was achieved through a randomized controlled trial (RCT) involving 65 patients I recruited from the emergency department at Columbia University Medical Center. I also conducted a survey of admitting clinicians who had patients participate in the trial to identify the impact on clinician practices and to elicit feedback on their perceptions of the intervention. Results: My research findings suggest that increased patient information sharing in the inpatient setting is beneficial and desirable to patients, and generally acceptable to clinicians. The clinician survey from Aim 1 showed that most respondents were comfortable with the idea of providing patients with their clinical information. Some expressed reservations that patients might misunderstand information and become unnecessarily alarmed or offended. In the patient field study from Aim 1, patients reported perceiving the information they received as highly useful, even if they did not fully understand complex medical terms. My primary contribution in Aim 2 was to provide sound evidence that the Patient Activation Measure is a valid and reliable tool for use in the inpatient setting. Establishing the validity and reliability of the PAM instrument in inpatient setting was essential for conducting the RCT in Aim 3, and it will provide a foundation for future clinicians and research investigators to measure and understand hospital patients’ levels of engagement. The results from the RCT in Aim 3 did not support my primary hypothesis that clinicians who had patients participate in their medication review process using an informatics tool would make more changes to the home medication list than clinicians who had patients in the control group. However, the results did suggest that most hospital patients are knowledgeable, willing, and able to contribute useful and important information to the medication reconciliation process. Interestingly, the clinicians I surveyed seemed far less convinced that their patients would be able to beneficially participate in the medication reconciliation process due to low health literacy and other barriers. Nevertheless, the clinicians did seem to believe that in theory, at least, patient involvement in the medication reconciliation process could have positive impacts on their workflow and potentially save them time. Conclusion: The overall theme resulting from my research is that patients can be a valuable resource to improve patient safety in the hospital. Patients are generally knowledgeable and willing to more actively participate in their hospital care. By developing the structures and processes to facilitate greater patient engagement, hospitals can provide an extra layer of safety and error prevention, particularly with respect to the medications patients take at home. As with any medical treatment, active participation in patient safety efforts may not be possible for all patients. However, I believe that if the culture of a hospital encourages openness and transparency, and if patients are given the proper tools and information, the quality and safety of hospital care will improve.

The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

Comumente, o cuidado ao paciente é prestado de forma bem-sucedida, no entanto, por mais preparada e capacitada que uma equipe de trabalho esteja, erros poderão acontecer. O gerenciamento de riscos cria alternativas para diminuir ou eliminar as falhas, que podem ocorrer durante a prática dos profissionais, e os enfermeiros desempenham papel de destaque nesse gerenciamento, pois exercem variadas funções dentro das instituições de saúde sendo os responsáveis pelo cuidado durante as 24 horas. O objetivo deste estudo foi analisar o gerenciamento da segurança do paciente junto aos Serviços de Enfermagem de hospitais do interior do Estado de São Paulo, por meio de pesquisa com os enfermeiros responsáveis técnicos e enfermeiros coordenadores das áreas assistenciais e apoio. Trata-se de estudo descritivo, não experimental, com delineamento transversal. Para coleta dos dados, foram elaborados dois instrumentos com questões de múltipla escolha, utilizando-se como base o questionário da Agency for Healthcare Research and Quality (AHRQ). Os dados foram organizados e analisados por meio de estatística descritiva, utilizando-se o software SPSS. O estudo foi realizado em 7 hospitais, com 56 sujeitos sendo, 7 responsáveis técnicos e 49 coordenadores. O tempo de formação profissional, para 100% dos responsáveis técnicos ficou acima de 9 anos e dos coordenadores variou de 2 a mais de 14 anos. Dentre os pesquisados, 85,7% dos responsáveis técnicos e 79,6% dos coordenadores referiram possuir cursos de pós- graduação. O estudo revelou que 100% dos hospitais pesquisados possuem sistema de notificação de eventos adversos, 71,4% possuem comissão de gerenciamento de riscos implantada. Dentre os coordenadores, 87,7% relataram que notificam quando o erro atinge o paciente, 81,7% notificam quando o erro tem potencial para prejudicar o paciente e 49% notificam quando se trata de um quase erro. Destaca-se que 12,3% coordenadores referiram relatar às vezes, raramente ou não relatam, mesmo que o erro atinja o paciente. Dentre os eventos adversos mais comumente notificados destacam-se os erros com medicações, perdas de cateteres, quedas, flebites e úlceras por pressão. Nos últimos 12 meses, 38,7% dos coordenadores referiram que realizaram entre 1 a 5 notificações. Outro ponto destacado por 89,8% dos coordenadores é o medo que os funcionários sentem que os erros sejam inscritos em suas fichas funcionais. Quanto às condutas com os eventos adversos notificados, 100% dos responsáveis técnicos referiram discutir os casos e capacitar as equipes. Em relação ao apoio da administração para implantação de medidas de segurança no hospital, a concordância entre os responsáveis técnicos foi de 100% e 93,9% dentre os coordenadores, mesmo assim, 85,7% dos responsáveis técnicos classificaram a segurança da assistência prestada aos pacientes no hospital como aceitável, diferentemente de 73,5% coordenadores que consideraram excelente ou muito boa. Os resultados evidenciaram a necessidade de desenvolver em todas as instituições uma cultura institucional não punitiva diante da ocorrência de eventos adversos, definição de políticas claras focadas na segurança do paciente, fortalecimento das comissões de gerenciamento de riscos, incentivo às notificações dos eventos adversos e análise das causas-raiz para que mudanças e barreiras consistentes nos processos possam garantir resultados assistenciais com melhor qualidade. / Patient care delivery tends to be successful but, no matter how prepared and trained a team is, errors can happen. Risk management creates alternatives to reduce or eliminate mistakes, which can take place in professional practice, and nurses play a paramount role in this management, as they have different functions in health institutions and are responsible for 24-hour care. The aim in this study was to analyze patient safety management in hospital nursing services in the interior of São Paulo State, Brazil, through a study that involved the nurses who acted as technical managers and as care and support coordinators. A descriptive and non-experimental study with a cross-sectional design was carried out. To collect the data, two instruments with multiple-choice questions were elaborated, based on the questionnaire of the Agency for Healthcare Research and Quality (AHRQ). Data were organized and analyzed with the help of descriptive statistics, using SPSS software. The study was undertaken at seven hospitals, involving 56 subjects: 7 technical managers and 49 coordinators. As regards the time since graduation, 100% of the technical managers had graduated more than nine years earlier, while that of the coordinators ranged between two and more than 14 years. Among the subjects, 85.7% of the technical managers and 79.6% of the coordinators indicated a graduate degree. The study revealed that 100% of the research hospitals have an adverse event notification system and 71.4% an active risk management commission. Among the coordinators, 87.7% indicated notification when the error reaches the patient, 81.7% when the error can harm the patient and 49% in case of a quasi-error. It is highlighted that 12.3% of the coordinators indicated that they sometimes, hardly or never notify, even when the error affects the patient. The most commonly notified adverse events include medication errors, catheter losses, falls, phlebitis and pressure ulcers. In the previous 12 months, 38.7% of the coordinators indicated between one and five notifications. Another point 89.8% of the coordinators highlighted is the employees\' fear that the errors will be registered in their employee files. Concerning conducts towards adverse event notifications, 100% of the technical managers indicate they discuss the cases and train the teams. With regard to management support to put in practice safety measures at the hospital, agreement levels amounted to 100% among the technical managers and 93.3% among the coordinators. Nevertheless, 85.7% of the technical managers classified the safety of patient care in the hospital as acceptable, while 73.5% of the coordinators found it excellent or very good. The results evidenced the need, at all institutions, to develop a non-punitive institutional culture towards the occurrence of adverse events, to define clear patient safety policy, strengthen risk management commissions, encourage adverse event notifications and analyze the root causes, so that consistent changes and barriers in processes can guarantee better-quality care results.