Bakgrund: Stödpersoner är en utomstående resurs som är frikopplad vårdapparaten och kan tilldelas patienter som vårdas under psykiatrisk tvångsvård. Stödpersonens arbete syftar till att stötta patienten i en sårbar period i livet genom social interaktion och uppmuntran. Syfte: Att undersöka vårdpersonalens erfarenheter av och uppfattningar om stödpersonens roll och betydelse för patienter inom psykiatriskt tvångsvård. Metod: Deskriptiv design med en kvalitativ ansats. Som datainsamlingsmetod användes intervjuer med nio öppna frågor. Ett bekvämlighetsurval gjordes för att uppnå åtta informanter ur vårdpersonalen på en psykiatrisk avdelning. Som analysmetod användes innehållsanalys. Joyce Travelbees omvårdnadsteori användes som utgångspunkt. Resultat: Vårdpersonalen hade överlag, trots viss variation, god kunskap och erfarenhet av stödpersoner och deras roll. Stödpersonen uppfattades också ha en generellt positiv och stärkande roll för patienten. Slutsats: Vårdpersonalen visste att stödpersoner fanns men det rådde viss oklarhet i vad som ingick i deras arbetsuppgifter. Stödpersoner uppfattades dock ha en meningsfull roll i patientens välbefinnande. Den upplevda känslan var att stödpersonen kunde bidra med ett medmänskligt stöd i en utsatt situation och att det var av stor betydelse för patienten. / Background: Support persons are an outside resource who are disconnected from the healthcare system and can be assigned to patients who are cared for during involuntary treatment. The support person's work aims to support the patient in an vulnerable period in life through social interaction and encouragement. Purpose: To investigate the healthcare staff's experience and opinions about the support person's role and importance for patients in psychiatric compulsory care. Methods: Descriptive design with a qualitative approach. As a data collection method, interviews with nine open ended questions were used. A convenience selection was made to achieve eight informants from the healthcare staff at a psychiatric department. As analysis method, content analysis was used. Joyce Travelbees' nursing theory was used as a starting point. Results: Overall, the healthcare staff had good knowledge and experience of support persons and their role, despite some variation. The support person was also perceived to have a generally positive and strengthening role for the patient. Conclusion: The healthcare staff knew that support persons existed, but there was some uncertainty in what was included in their duties. However, support persons were perceived to have a meaningful role in the patient's well-being. The feeling was that the support person could contribute with a charitable support in a vulnerable situation and that it was of great importance to the patient

Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow. The aim of this doctoral research was to explore this under-researched area in three phases. Phase one: - Phase one focused on critically appraising and synthesising the available evidence on healthcare professionals’ perceptions, attitudes, and views of the facilitators and barriers to implementing electronic prescribing, electronic dispensing, and/or electronic administration of medicines in the hospital setting. The review protocol was registered with the Centre for Reviews and Dissemination and conducted according to best practice. Key facilitators included systems improved patient safety and provided better access to patients’ drug records and that team leadership and hardware/software availability and reliability were essential for successful implementation. Key barriers consisted of hardware and network problems, altered work practices, and weakened interpersonal communication between healthcare professionals and with patients. Phase two: - This phase employed a qualitative phenomenological design to gain original insight into the perceptions of local key stakeholders towards the facilitators and barriers to implementing prescribing, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospitals in Ireland using Normalization Process Theory as a theoretical framework. Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two hospital Information Technology managers. Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multidisciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action. Phase three: - A similar qualitative methodology was employed in phase three of this research in order to explore the perceptions of national key stakeholders and eHealth leads towards the facilitators and barriers to system implementation. Sixteen consenting invitees participated: eight hospital leads, four government leads, two regulatory leads, and two academics. Key facilitators included enhanced patient safety, workflow efficiencies, improvements in governance, and financial gains. Perceived barriers included the introduction of new drug errors, loss of patient contact, initial time inefficiencies, and issues with the complexity of integration and standardisation of work processes. Overall, adequate technology, stakeholder involvement, and organisational leadership and support are required at a national and local level to drive the eHealth agenda forward. Testing at scale, contingency plans, and ongoing evaluations will assist in determining success or otherwise of system implementation. This research has generated novel findings with many potentially transferable themes identified which extend the evidence base. This will assist organisations to better plan for implementation of medication-related eHealth systems.

Bakgrund: Våld i nära relationer mot kvinnor är ett globalt folkhälsoproblem och skapar ett lidande hos de utsatta på flera plan och dessa kvinnor är i särskilt behov av stöd. Vårdpersonal har en viktig roll i att möta dessa kvinnor, där hela människan måste tas i beaktande. Kunskapsbrist och organisatoriska brister försvårar mötet med kvinnor som blivit utsatta för våld. Syfte: Beskriva hur kvinnor som blivit utsatta för våld i nära relationer upplevde omvårdnaden från vårdpersonalen. Metod: Litteraturöversikt där elva kvalitativa artiklar analyserades. Resultat: I resultatet framkommer det fyra huvudteman och två subteman. (1) Vårdpersonalens attityder och bemötande; vikten av tid, utsatt patientgrupp. (2) Betydelsen av att vårdpersonal frågar om våld. (3) Fokus på symtom. (4) Upplevelser av stöd och hjälp. Konklusion: Vårdpersonal behöver mer utbildning, tydliga riktlinjer och stöd/handledning från arbetsplatsen. Relationen mellan vårdpersonal och den utsatta kvinnan behöver präglas av en trygg miljö, tillit och medmänsklighet. / Background: Violence against women is a major public health problem and creates a suffering on several levels and these women are in particular need of support. Healthcare professionals have an important role in meeting these women, where the whole person must be considered. Lack of knowledge and organizational shortcomings complicate the encounter with women who have been exposed to violence. Aim: The aim of this study was to describe women’s experiences of care whom been a victim of violence in close relationship. Method: Literature review where eleven qualitative articles were analyzed. Result: The result shows four main themes and two sub-themes. (1) Attitudes and treatment of healthcare professionals; the importance of time, exposed patient group. (2) The importance of healthcare professionals asking about violence. (3) Focus on symptoms. (4) Experiences of support and help. Conclusion: Healthcare professionals need more education, clear guidelines and support/supervision from the workplace. The relationship between healthcare professionals and the women needs to be characterized by a safe environment, trust and compassion.

HIV-related stigma and discrimination is a complex concept that affects HIV reduction interventions. HIV-related stigma occurs among healthcare providers resulting in reduction of quality of care of people living with HIV. Social psychological research into stigma reduction has led to the development of many stigma reduction interventions, but has not resolved the underlying problem. This study was designed to identify predictors of stigmatizing behavior among healthcare workers in Ghana using the social cognitive theory (SCT) for use in developing an evidence-based intervention. The study used a cross-sectional research design incorporating a preexisting survey, Measuring HIV Stigma and Discrimination Among Health Staff: Comprehensive Questionnaire. Survey data were analyzed using descriptive, multiple regression analysis and Pearson's coefficient to estimate the relationship between the dependent variable, HIV related stigmatizing behavior, and independent variables, personal attributes and environmental factors. The key findings from the analysis were that the personal attributes of healthcare workers predicted their stigmatizing behavior (R2= 0.674, p < 0.05). There was, however, no significant relationship between environmental factors and stigmatizing behavior and between personal attributes and environmental factors. The social change implications may be to reduce stigma among healthcare workers toward people living with HIV and in turn increase the willingness of healthcare workers to engage with people living with HIV and provide quality service to them.

This thesis investigated whether out­come after in-hospital cardiac arrest patients could be improved by a cardiopulmonary resuscitation (CPR) educational intervention focusing on all hospital healthcare professionals. Annually in Sweden, approximately 3000 in-hospital patients suffer a cardiac arrest in which CPR is attempted, and which 900 will survive. The thesis is based on five papers: Paper I was a methodological study concluding in a reliable multiple choice questionnaire (MCQ) aimed at measuring CPR knowledge. Paper II was an intervention study. The intervention consisted of educating 3144 healthcare professionals in CPR. The MCQ from Paper I was answered by the healthcare professionals both before (82% response rate) and after (98% response rate) education. Theoretical knowledge improved in all the different groups of healthcare professionals after the intervention. Paper III was an observational laboratory study investigating the practical CPR skills of 74 healthcare professionals’. Willingness to use an automated external defibrillator (AED) improved generally after educa­tion, and there were no major differences in CPR skills between the different healthcare professions. Paper IV investigated, by use of a questionnaire, the attitudes to CPR of 2152 healthcare professionals (82% response rate). A majority of healthcare professionals reported a positive attitude to resuscitation. Paper V was a register study of patients suffering from cardiac arrest. The intervention tended not to reduce the delay to start of treatment or to increase overall survival. However, our results suggested indirect signs of an improved cerebral function among survivors. In conclusion, CPR education and the introduction of AEDs in-hospital – improved healthcare professionals knowledge, skills, and attitudes – did not improve patients’ survival to hospital discharge, but the functional status among survivors improved.

Introdução: Os erros de medicação em hospitais têm origem multidisciplinar e multifatorial, podendo ocorrer em qualquer uma das etapas do processo de utilização dos medicamentos. A constatação de que os erros podem ocorrer implica no reconhecimento de que medidas devem ser tomadas. Os erros de medicação não devem ser banalizados, nem magnificados, devem ser adequadamente abordados em todas as suas repercussões pessoais, profissionais e institucionais. O Modelo de Bioética Complexa é um referencial adequado para abordar a temática dos erros de medicação, por refletir sobre situações de complexidade crescente, incluindo os múltiplos aspectos envolvidos. Objetivos: Avaliar o sistema de notificação de erros de medicação do HCPA segundo o referencial da Bioética Complexa. Analisar a percepção de colaboradores das áreas de Enfermagem, Farmácia e Medicina sobre a notificação e o monitoramento dos erros de medicação na Instituição. Identificar as barreiras para a notificação dos erros de medicação. Identificar os facilitadores para a notificação dos erros de medicação. Identificar os motivos para realizar a notificação de erros de medicação. Método: Trata-se de um estudo descritivo e exploratório. Foi realizada uma pesquisa online através da ferramenta Formulários Google®. O questionário, composto por 9 perguntas, foi elaborado tendo como referência perguntas de estudo prévio sobre o tema. O questionário era anônimo, não sendo possível identificar os participantes. Por e-mail institucional do HCPA, foi enviado convite com o endereço eletrônico para acessar o instrumento de coleta de dados. Não foram incluídos colaboradores vinculados ao Programa de Gestão da Qualidade e da Informação em Saúde (QUALIS) e à Gerência de Risco (GR), bem como coordenadores e assessores do HCPA. O envio dos e-mails foi realizado em um período de 60 dias. Foram realizados 2 a 4 envios, em diferentes dias da semana. Foi obtida uma amostra aleatória de 411 participantes, de um total de 3872 colaboradores (profissionais de nível superior das áreas de Medicina, Enfermagem e Farmácia, contratados ou residentes, e técnicos de Enfermagem e de Farmácia). O conteúdo das respostas às perguntas abertas do questionário foi submetido à técnica de análise de conteúdo de Bardin. Os dados foram armazenados e avaliados no software de análise qualitativo QSR NVivo® versão 10. Resultados: Foram identificadas três categorias principais de barreiras: Barreiras Individuais, Barreiras Organizacionais e Barreiras Culturais. Na categoria Barreiras Individuais, emergiram seis subcategorias: medo, desconhecimento, responsabilidade, falta de comprometimento, esquecimento e vergonha. Na categoria Barreiras Organizacionais, emergiram quatro subcategorias: demanda de trabalho, dificuldades com o sistema de notificação, falta de feedback e infraestrutura. Na categoria Barreiras Culturais, emergiram três subcategorias: cultura de segurança não priorizada, cultura de banalização dos erros e cultura de infalibilidade. O medo foi a barreira individual mais referida pelos participantes. A demanda de trabalho foi percebida como uma das principais barreiras organizacionais pelos colaboradores e foi relacionada à falta de tempo. A partir da análise das respostas dos participantes, emergiram 12 categorias de facilitadores para a notificação dos erros de medicação: Divulgação e informação, Condução adequada da análise, Sistema de notificação, Resposta não punitiva, Feedback, Clareza, Cultura, Treinamento, Anonimato, Trabalho em equipe, Demanda de trabalho e Comprometimento. Doze categorias foram identificadas como motivos para notificar os erros de medicação. As categorias foram agrupadas quanto à sua relação com os profissionais, com os processos e com os pacientes. Motivos relacionados ao profissional: a Educação, a Proteção do Profissional envolvido em um erro de medicação e a Responsabilidade. Motivos relacionados aos processos envolvidos: Prevenir novos erros, Revisão dos processos, Análise dos erros, Barreiras de segurança, Protocolo Institucional e Cultura de segurança. Motivos relacionados aos pacientes: Segurança do Paciente, Qualidade da assistência e Riscos. Considerações finais: Verifica-se o engajamento dos profissionais participantes que deram inúmeras contribuições para o entendimento e aprimoramento do processo de notificação de erros de medicação, com uma ênfase na segurança do paciente. / Background: Medication errors in hospitals have multidisciplinary and multifactorial origin and can occur at any stage of the process of use of medicines. The finding that errors may occur involves the recognition that measures should be taken. Medication errors should not be trivialized or magnified, they should be adequately addressed in all their personal, professional and institutional repercussions. The Complex Bioethics model is an appropriate framework to address the issue of medication errors, by reflecting on the increasing complexity of situations, including the many aspects involved. Objective: To evaluate the medication error reporting system of the HCPA under the framework of Complex Bioethics. To analyze the perception of employees in the areas of Nursing, Pharmacy and Medicine on the reporting and monitoring of medication errors in the institution. Identify barriers to the reporting of medication errors. Identify facilitators for reporting of medication errors. Identify the reasons to perform medication error reporting. Method: This is a descriptive and exploratory study. It was done a search online through Google Forms tool. The questionnaire consists of 9 questions, it has been established as a previous study questions reference on the subject. The questionnaire was anonymous, it is not possible to identify participants. Email invitation has been sent to the email address of the participants to access the questionnaire. The sending of e-mails was conducted in a period of 60 days. A random sample of 411 participants was obtained, a total of 3872 employees. The content of the answers to open questions of the questionnaire was submitted to Bardin content analysis technique. The data were stored and evaluated by qualitative analysis software QSR NVivo version 10. Results: We identified three main categories: individual barriers, organizational barriers and cultural barriers. In the category individual barriers emerged six sub-categories: fear, ignorance, responsibility, lack of commitment, forgetfulness and shame. In the category organizational barriers, four subcategories emerged: workload, difficulties with the reporting system, lack of feedback and infrastructure. In the category cultural barriers revealed three subcategories: not prioritized safety culture, banalization of errors and infallibility culture. Fear was the individual barrier most reported by the participants. The workload was perceived as a major organizational barrier by employees and was related to lack of time. From the analysis of the responses of the participants emerged 12 categories of facilitators for the reporting of medication errors: shared information, proper conduct of the analysis, reporting system, non- punitive response, feedback, clarity, culture, training, anonymity, teamwork, workload and commitment. Twelve categories were identified as reasons for reporting medication errors. The categories were grouped as to its relationship with the professionals, with the procedures and with patients. Reasons related to Professional: education, professional protection and responsibility. Reasons related to the processes involved: To prevent new errors, review of processes, analysis of errors, safety barriers, institutional protocol and safety culture. Reasons related to patients: patient safety, quality of care and risks. Conclusion: There is the engagement of the professionals who gave numerous contributions to the understanding and improvement of medication errors notification process, with an emphasis on patient safety.

Bakgrund: Personer med HIV föreligger ökad risk för olika infektioner på grund av deras låga immunförsvar. Omvårdnadsbehov för personer med HIV kan vara munhälsa, nutrition och psykiskt stöd. Det förekommer att vårdpersonal har otrevlig attityd mot personer med HIV och låg kunskapsnivå om sjukdomen. Syfte: Syftet med denna litteraturöversikt var att belysa hur personer med HIV upplever hälso- och sjukvården. Metod: En litteraturöversikt där elva vetenskapliga artiklar har sammanställts. Resultat: Resultatet presenteras i fyra huvudteman: Mötet med vårdpersonal, Stöd och kunskap och Smitta och sekretessbrott, Andra instanser och aspekter som inverkade på upplevelsen av hälso- och sjukvården. Diskussion: Diskussionen belyser hur patienter med HIV upplevde bemötande från vårdpersonalen och hur vårdpersonalens kunskapsnivå kan påverka bemötandet, samt att patienterna upplever att de har en kunskapsbrist om HIV. Resultatet diskuteras med hjälp av vetenskapliga artiklar och Katie Erikssons teori om ansa, leka och lära samt begreppet vårdlidande. Det har betydelse att utföra vårdhandlingar utifrån patientens behov för att minska vårdlidande. / Background: People with HIV has an increased risk of various infections due to their low immune system. Care needs for people with HIV can be a good oral health, nutrition and psychological support. Healthcare professionals can have a bad attitude towards people with HIV and low levels of knowledge about the disease. Aim: The purpose of this literature review was to illuminate how people with HIV experience the healthcare. Method: A literature review with eleven scientific articles have been compiled. Results: The result is presented in four main themes: Meeting with healthcare professionals, Support and knowledge and Contagion and confidentiality, Other instances and aspects that affected the experience of healthcare. Discussion: The discussion illustrates how patients with HIV experienced treatment from the healthcare staff and how the healthcare staff's level of knowledge can affect the treatment, and that patients experience a lack of knowledge about HIV. The key parts of the result were discussed with help of scientific articles and Katie Eriksson´s theory of tending, playing and teaching, as well as the concept of suffering related to care. It is important to carry out health care procedures based on the patient needs to suffering related to care.

Bakgrund: Kronisk smärta är ett globalt fenomen där var femte människa regelbundet upplever måttlig till svår smärta. Otillräcklig förståelse och kunskap om egenvård av kronisk smärta kan vara ett hinder för många äldre personer. Otillräcklig smärtlindring kan medföra onödigt lidande för patienten. Kronisk smärta kan också påverka den äldre personens vardag så väl som deras livskvalité. Syfte: Syftet med studien var att belysa hälso- och sjukvårdspersonalens erfarenhet av omvårdnad hos äldre personer med kronisk smärta. Metod: Denna studie var en litteraturöversikt med induktiv design med 11 kvalitativa artiklar som urval. Resultat: Hälso- och sjukvårdspersonalen uttryckte att det fanns ett ökat behov av kunskap om smärta, eftersom de stundtals tvivlade på sin egen förmåga att bedöma och lindra smärtan hos äldre personer, vilket gav en känsla av maktlöshet. Erfarenheten var att samarbete, tillit och en fungerande kommunikation inom det multi-professionella teamet var viktigt för att patientens smärtlindring skulle bli optimal. Slutsats: För att den äldre patienten med kronisk smärta ska få en god smärtlindring krävs att hälso- och sjukvårdspersonalen har kunskap, samarbetsförmåga och självinsikt. / Background: Chronic pain is a global phenomenon, where every fifth person experiences moderate to severe pain regularly. Insufficient understanding and knowledge of chronic pain can be an obstacle for elderly patients. Pain relief that is insufficient contributes to unnecessary suffering for the individual. Chronic pain can also influence elderly patients' everyday life, as well as their quality of life. Aim: The aim of this study was to describe the health care staffs’ experience of nursing in elderly patients with chronic pain. Method: This study was a literature review with an inductive design in addition to a selection of qualitative articles. Result: The health care staff expressed a need for increasing the knowledge about pain, as they sometimes doubted their ability to assess and alleviate the pain in the elderly, which gave a sense of the staff being powerless. The experience was that collaboration, trust, and a functioning communication within the multi-professional team had an important role for optimal pain relief. Conclusion: In order for the elderly patient with chronic pain to receive sufficient pain relief, the healthcare professionals need abilities such as knowledge, cooperation and self-awareness.

Meticillinresistent staphylococcus aureus (MRSA) är en bakterie som är resistent mot ett flertal antibiotika. Det är en bakterie som har ökat både i Sverige och i resten av världen. Tidigare var smittspridningen av MRSA vanligt förekommande på sjukhusen men har på senare tid även blivit allt mer förekommande utanför sjukvården. Att smittas av MRSA kan innebära svåra infektionssjukdomar som pneumoni, urinvägsinfektion och sepsis. För att minimera smittspridningen av MRSA flyttas patienter till isoleringssalar, vilket kan resulterat i lidande för patienten. Syfte är att belysa MRSA smittade patienters upplevelse av möten med hälso- och sjukvårdspersonal. Denna litteraturöversikt är baserad på tio vetenskapligt granskade artiklar, nio av artiklarna är kvalitativa och en är kvantitativ. De vetenskapliga artiklarna har noggrant granskats och därifrån har en sammanställning med teman till resultatet bildats. Databaserna CINAHL Complete, PubMed och Academic Search Complete har använts. Utifrån de tio artiklarna sammanställdes fyra teman som belyser patienters upplevelser. Dessa redovisas under i följande rubriker: Hälso- och sjukvård samt närståendes bemötande av patienter med MRSA, Psykologiskt trauma, Negativa och positiva upplevelser av isolering samt Kunskap om MRSA. Katie Erikssons teori med fokus på lidande diskuteras tillsammans med resultatet, utifrån patientens perspektiv. En av sjuksköterskornas centrala roll inom omvårdnadsarbetet är förebyggandet av smittspridning av MRSA, främst genom basala handhygienrutiner. Resultatet påvisade faktorer som kan påverka patienters syn på vården gällande MRSA. Där många patienter upplever att hälso- och sjukvårdspersonalen saknar kunskap angående smittspridning, infektioner och isoleringsrestriktioner. / Meticillin-resistant staphylococcus aureus (MRSA) is a bacteria that is resistant to a variety of antibiotics. This bacteria has increased both in Sweden and worldwide. Previously, the spread of MRSA was common in hospitals, but has recently become more common outside the healthcare sector. To be infected with MRSA often involves severe infectious such as pneumonia, urinary tract infection and sepsis. To minimize the spread of MRSA, patients are moved to isolation, which can result in suffering. To shed light on the experiences of MRSA-infected patients’ interactions with healthcare professionals. This literature review is based on ten scientifically reviewed articles, nine are qualitative and one is quantitative. The scientific articles have been carefully reviewed and from there have a summary with the themes to the result, been formed. Databases CINAHL Complete, PubMed and Academic Search Complete have been used. Based on the ten articles, four themes summarized the patient's experiences. These are listed under the following headings: Healthcare, and relatives response to patients with MRSA, Psychological trauma, Negative and positive experiences of insulation, and Knowledge of patients and healthcare professionals. Katie Eriksson's theory on suffering is discussed with the result, based on patient's perspective. One of the nurses' central role in nursing work is preventing contagious spread of MRSA, primarily through basic hand hygiene routines. Our results indicate that there are factors that may affect patients' views on the care of MRSA. Where many patients experience that healthcare professionals lack knowledge about spread of infection, infections and isolation restrictions.

Introdução: Os erros de medicação em hospitais têm origem multidisciplinar e multifatorial, podendo ocorrer em qualquer uma das etapas do processo de utilização dos medicamentos. A constatação de que os erros podem ocorrer implica no reconhecimento de que medidas devem ser tomadas. Os erros de medicação não devem ser banalizados, nem magnificados, devem ser adequadamente abordados em todas as suas repercussões pessoais, profissionais e institucionais. O Modelo de Bioética Complexa é um referencial adequado para abordar a temática dos erros de medicação, por refletir sobre situações de complexidade crescente, incluindo os múltiplos aspectos envolvidos. Objetivos: Avaliar o sistema de notificação de erros de medicação do HCPA segundo o referencial da Bioética Complexa. Analisar a percepção de colaboradores das áreas de Enfermagem, Farmácia e Medicina sobre a notificação e o monitoramento dos erros de medicação na Instituição. Identificar as barreiras para a notificação dos erros de medicação. Identificar os facilitadores para a notificação dos erros de medicação. Identificar os motivos para realizar a notificação de erros de medicação. Método: Trata-se de um estudo descritivo e exploratório. Foi realizada uma pesquisa online através da ferramenta Formulários Google®. O questionário, composto por 9 perguntas, foi elaborado tendo como referência perguntas de estudo prévio sobre o tema. O questionário era anônimo, não sendo possível identificar os participantes. Por e-mail institucional do HCPA, foi enviado convite com o endereço eletrônico para acessar o instrumento de coleta de dados. Não foram incluídos colaboradores vinculados ao Programa de Gestão da Qualidade e da Informação em Saúde (QUALIS) e à Gerência de Risco (GR), bem como coordenadores e assessores do HCPA. O envio dos e-mails foi realizado em um período de 60 dias. Foram realizados 2 a 4 envios, em diferentes dias da semana. Foi obtida uma amostra aleatória de 411 participantes, de um total de 3872 colaboradores (profissionais de nível superior das áreas de Medicina, Enfermagem e Farmácia, contratados ou residentes, e técnicos de Enfermagem e de Farmácia). O conteúdo das respostas às perguntas abertas do questionário foi submetido à técnica de análise de conteúdo de Bardin. Os dados foram armazenados e avaliados no software de análise qualitativo QSR NVivo® versão 10. Resultados: Foram identificadas três categorias principais de barreiras: Barreiras Individuais, Barreiras Organizacionais e Barreiras Culturais. Na categoria Barreiras Individuais, emergiram seis subcategorias: medo, desconhecimento, responsabilidade, falta de comprometimento, esquecimento e vergonha. Na categoria Barreiras Organizacionais, emergiram quatro subcategorias: demanda de trabalho, dificuldades com o sistema de notificação, falta de feedback e infraestrutura. Na categoria Barreiras Culturais, emergiram três subcategorias: cultura de segurança não priorizada, cultura de banalização dos erros e cultura de infalibilidade. O medo foi a barreira individual mais referida pelos participantes. A demanda de trabalho foi percebida como uma das principais barreiras organizacionais pelos colaboradores e foi relacionada à falta de tempo. A partir da análise das respostas dos participantes, emergiram 12 categorias de facilitadores para a notificação dos erros de medicação: Divulgação e informação, Condução adequada da análise, Sistema de notificação, Resposta não punitiva, Feedback, Clareza, Cultura, Treinamento, Anonimato, Trabalho em equipe, Demanda de trabalho e Comprometimento. Doze categorias foram identificadas como motivos para notificar os erros de medicação. As categorias foram agrupadas quanto à sua relação com os profissionais, com os processos e com os pacientes. Motivos relacionados ao profissional: a Educação, a Proteção do Profissional envolvido em um erro de medicação e a Responsabilidade. Motivos relacionados aos processos envolvidos: Prevenir novos erros, Revisão dos processos, Análise dos erros, Barreiras de segurança, Protocolo Institucional e Cultura de segurança. Motivos relacionados aos pacientes: Segurança do Paciente, Qualidade da assistência e Riscos. Considerações finais: Verifica-se o engajamento dos profissionais participantes que deram inúmeras contribuições para o entendimento e aprimoramento do processo de notificação de erros de medicação, com uma ênfase na segurança do paciente. / Background: Medication errors in hospitals have multidisciplinary and multifactorial origin and can occur at any stage of the process of use of medicines. The finding that errors may occur involves the recognition that measures should be taken. Medication errors should not be trivialized or magnified, they should be adequately addressed in all their personal, professional and institutional repercussions. The Complex Bioethics model is an appropriate framework to address the issue of medication errors, by reflecting on the increasing complexity of situations, including the many aspects involved. Objective: To evaluate the medication error reporting system of the HCPA under the framework of Complex Bioethics. To analyze the perception of employees in the areas of Nursing, Pharmacy and Medicine on the reporting and monitoring of medication errors in the institution. Identify barriers to the reporting of medication errors. Identify facilitators for reporting of medication errors. Identify the reasons to perform medication error reporting. Method: This is a descriptive and exploratory study. It was done a search online through Google Forms tool. The questionnaire consists of 9 questions, it has been established as a previous study questions reference on the subject. The questionnaire was anonymous, it is not possible to identify participants. Email invitation has been sent to the email address of the participants to access the questionnaire. The sending of e-mails was conducted in a period of 60 days. A random sample of 411 participants was obtained, a total of 3872 employees. The content of the answers to open questions of the questionnaire was submitted to Bardin content analysis technique. The data were stored and evaluated by qualitative analysis software QSR NVivo version 10. Results: We identified three main categories: individual barriers, organizational barriers and cultural barriers. In the category individual barriers emerged six sub-categories: fear, ignorance, responsibility, lack of commitment, forgetfulness and shame. In the category organizational barriers, four subcategories emerged: workload, difficulties with the reporting system, lack of feedback and infrastructure. In the category cultural barriers revealed three subcategories: not prioritized safety culture, banalization of errors and infallibility culture. Fear was the individual barrier most reported by the participants. The workload was perceived as a major organizational barrier by employees and was related to lack of time. From the analysis of the responses of the participants emerged 12 categories of facilitators for the reporting of medication errors: shared information, proper conduct of the analysis, reporting system, non- punitive response, feedback, clarity, culture, training, anonymity, teamwork, workload and commitment. Twelve categories were identified as reasons for reporting medication errors. The categories were grouped as to its relationship with the professionals, with the procedures and with patients. Reasons related to Professional: education, professional protection and responsibility. Reasons related to the processes involved: To prevent new errors, review of processes, analysis of errors, safety barriers, institutional protocol and safety culture. Reasons related to patients: patient safety, quality of care and risks. Conclusion: There is the engagement of the professionals who gave numerous contributions to the understanding and improvement of medication errors notification process, with an emphasis on patient safety.