SAMMANFATTNING BAKGRUND: För att hälso- och sjukvården ska kunna hålla en hög kvalitet och fortsätta att utvecklas är det viktigt att uppmärksamma när patienter anser sig felbehandlade av vården. Vårdgivaren är skyldig att granska och utreda händelser och klagomål rörande vårdskador (SFS 2010:659), och patientnämnden har som samhällsinstans en central roll att på landstingsnivå granska patientärenden och utgöra en opartisk bro mellan patient och hälso- och sjukvård. Det är viktigt att belysa förekomsten och typen av anmälningsärenden för att kunna bedriva kontinuerligt förbättringsarbete. SYFTE: Syftet med denna studie är att kvantitativt beskriva de anmälningar rörande vårdskador som inkommit till patientnämnden i ett landsting i Mellansverige under 2015. METOD: Denna studie är en empirisk retrospektiv studie med kvantitativ ansats. Ärendena inhämtades från patientnämnden. Totalt 893 ärenden inkom till patientnämnden år 2015 och samtliga ärenden granskades. Därefter inkluderades 229 ärenden som kategoriserades med hjälp av en modifierad granskningsmall. RESULTAT: De vanligaste förekommande anledningarna till anmälan om vårdskada är misstanke eller upplevelse av felbehandling respektive feldiagnos (54 %). Kirurgi- och onkologidivsionen är den division varifrån flest ärenden kommer (41 %). Majoriteten (74 %) av ärendena anmäls av patienten själv. Kvinnor står för fler anmälningar till patientnämnden än män (65 % vs 35 %).  I 41 % av de granskade fallen har berörd divison fastställt att vårdskada inträffat. SLUTSATS: Totalt 229 ärenden bedömdes som vårdskador. Det behövs vidare forskning för att bekräfta studiens resultat. Nyckelord: patientsäkerhet, vårdskador, patienträttigheter / ABSTRACT BACKGROUND: It´s important to acknowledge when patients consider themselves mistreated, in order to strive for better and safer health care. The caregiver is obliged to investigate events and complaints resulting in patient injuries (SFS 2010:659). Patientnämnden is an organizational unit within the county and it has a central role in reviewing patient complaint cases, being an impartial bridge between the patient and the health care. OBJECTIVE: The aim of this study is to describe the complaints regarding patient injuries from a county in mid Sweden 2015. METHODS: An empirical retrospective study with a quantative approach was conducted. The data was collected from patientnämnden. A total of 893 complaints were received by patientnämnden during the year 2015. All of the complaints were reviewed. Two hundred twenty-nine complaints were included and categorized with a modified examination instrument. RESULTS: The most common reason for complaints regarding patient injuries are mistreatment and misdiagnosis (54 %). Most of the complaints come from the surgery and oncology division (41 %). The majority (74 %) of the complaints is reported by the patient, and it´s more common for women compared to men to file complaints to patientnämnden (65 % vs 35 %). In 41 % of the cases, a medical injury was confirmed by the caregiver in some way. CONCLUSION: A total of 229 complaints was categorized as patient injuries. More research are needed to confirm the result of this study. Keywords: patient safety, patient harm, patient rights

Bakgrund: Varje år drabbas nästan var tionde patient av skador under vårdtiden, skador som hade kunnat undvikas. Detta leder till ett onödigt lidande för dessa patienter och deras närstående. Vårdskadorna beräknas enligt Socialstyrelsen (2008) kosta samhället sex miljarder kronor per år. Operationssjuksköterskor liksom all vårdpersonal har skyldighet att avvikelserapportera händelser som kunnat leda till eller lett till vårdskada. Syftet med att rapportera avvikelser är att dra lärdom och att med riskförebyggande insatser förhindra att händelserna uppstår igen. Syfte: Att studera vilken erfarenhet operationssjuksköterskor har av avvikelserapportering. Metod: Studien utfördes som en tvärsnittsstudie med kvantitativ ansats. Ett studiespecifikt frågeformulär innehållande tio strukturerade frågor med möjlighet till egna kommentarer användes. Formulärets frågor behandlade erfarenheter kring avvikelserapportering. Resultat: En stor majoritet av deltagarna (85 %) hade någon gång avstått från att skriva avvikelserapport. Slutsatser: Bland annat var tidsbrist en avgörande faktor varför operationssjuksköterskorna inte dokumenterade en avvikelserapport. / Background: Each year, nearly every tenth patient suffers of injuries during hospitalization, which could have been avoidable. This leads to unnecessary suffering for the patients and their families. Health damage according to the National Board (the Swedish Socialstyrelsen) (2008) costs the society six billion Swedish kronor (SEK) every year. It is mandatory for theatre nurses to report incidents that could have coast injuries to the patient during hospitalization. The purpose with incident reports is to learn from mistakes and with preventive measurements make the healthcare safer for the patients. Aim: To evaluate theatre nurses experience with reporting incidents. Method: The study was conducted as a cross-sectional design with quantitative data. A study- specific questionnaire comprising ten structured questions with the possibility of their comments was used. The form´s questions dealt with experiences about incident reporting. Result: A large majority of respondents (85 %) had at some point refrained from writing incident reports. Conclusions: Among other things, lack of time was the decisive factor why theatre nurses were not documented an incident report.

Orientador: Patrícia de Carvalho Mastroianni / Resumo: Estima-se que a notificação espontânea de incidentes capture apenas 10% dos eventos ocorridos em instituições hospitalares. Entretanto, a educação em saúde pode contribuir para o estímulo do aumento do índice de notificações assim como para a segurança do paciente. Diante disso, o objetivo do estudo foi avaliar a efetividade de uma Intervenção Educativa (IE) para promoção da notificação de incidentes em saúde para profissionais de um hospital de ensino no interior do estado de São Paulo. O estudo foi do tipo experimental, aberto, não randomizado e houve adaptação da IE através de um pré-treinamento com alunos de graduação da Faculdade de Ciências Farmacêuticas da Unesp. Os profissionais incluídos no estudo foram aqueles cuja atuação fosse da área assistencial. Foram excluídos, profissionais afastados por um período maior do que três meses, estagiários e residentes. A participação dos profissionais na IE foi feita através da alocação por conveniência, com formação de três turmas, de acordo com turno de trabalho dos participantes. A IE foi realizada durante três meses, por meio de aulas expositivas, divididas em quatro módulos com duração de 60 minutos cada, realizados em dias alternados por duas semanas, além da aplicação de questionário antes e depois. As variáveis analisadas estavam relacionadas ao conhecimento, habilidade e atitude em notificação. As respostas dos questionários, assim como a quantidade e qualidade dos itens preenchidos na ficha de notificação foram avaliada... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

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Medical errors are the 3rd leading cause of death in the U.S.. The problem is timely recognition and management of inappropriate healthcare worker behaviors that lead to intimidation and loss of staff focus, eventually leading to errors. The purpose of this qualitative modified Delphi study was to seek consensus among a panel of experts in hospital risk management practices on the practical methods for early detection of inappropriate behaviors among hospital staff, which may be used by hospital managers to considerably mitigate the risk of medical mishaps. High reliability theory guided the research process, utilizing the conceptual framework of fair and just culture patient safety model. A single research question asked what level of consensus exists among hospital risk management experts as to the practical methods for early detection of inappropriate behavior among hospital staff, which managers may use to ultimately mitigate the risk of preventable medical mishaps. This study included nonprobability purposive sampling (n=34) and 3 rounds of questionnaires. Consensus was reached on 8 factors: setting expectations, developing a culture of respect, holding staff accountable, enforcing a zero-tolerance policy, confidentiality of reporting, communicating expected behavior, open communication, and investigating inappropriate behaviors. The implications for positive social change include a better understanding of inappropriate behaviors among healthcare workers as well as the potential to minimize its negative impacts and improve patient safety in healthcare organizations.

Research shows that, when unintentional harm to patients in outpatient and hospital settings occurs, root cause analysis (RCA) investigations should be conducted to identify and implement corrective actions to prevent future patient harm. Executives at a small healthcare consulting company that employs patient safety officers (PSOs) responsible for conducting RCAs were concerned with the low quality of RCA outcomes, prompting this postinvestigation assessment of PSOs' RCA training and experiences. Guided by adult learning theory, the purpose of this study was to assess PSOs' RCA training and investigation experiences by examining self-reported benefits, attitudes, barriers, and time since training, and the relationship between time since training and the number of barriers encountered during RCA investigations. This quantitative study used a preestablished survey with a purposeful sample of 89 PSOs located at 75 military health care facilities in the United States and abroad. Data analysis included descriptive statistics and Kendall's tau-b correlations. Results indicated that PSOs had positive training experiences, valued RCA investigations, varied on the time since RCA training, and encountered barriers conducting RCAs. Kendall's tau-b correlation analysis showed that the time since training was not significantly associated with the frequency of barriers they encountered. Findings suggest that the transfer of technical RCA knowledge was applied during actual RCA investigations regardless of time since training, and barriers contributed to subpar quality RCA outcomes. RCA professional development was designed to enhance nontechnical, soft competency skills as a best practice to overcome encountered barriers and promote social change in the field.

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