Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-06T12:19:03Z No. of bitstreams: 1 lidianemirandamilagres.pdf: 1039453 bytes, checksum: 443b4aa86756817eaf9f0ce5ef68ff8c (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T16:11:28Z (GMT) No. of bitstreams: 1 lidianemirandamilagres.pdf: 1039453 bytes, checksum: 443b4aa86756817eaf9f0ce5ef68ff8c (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T16:15:06Z (GMT) No. of bitstreams: 1 lidianemirandamilagres.pdf: 1039453 bytes, checksum: 443b4aa86756817eaf9f0ce5ef68ff8c (MD5) / Made available in DSpace on 2016-01-25T16:15:06Z (GMT). No. of bitstreams: 1 lidianemirandamilagres.pdf: 1039453 bytes, checksum: 443b4aa86756817eaf9f0ce5ef68ff8c (MD5) Previous issue date: 2015-07-03 / Este estudo trata da gestão de risco como estratégia para segurança do paciente. Tem por objeto de estudo o processo de notificação dos eventos adversos. Os objetivos traçados foram: identificar o conhecimento de enfermeiros acerca de evento adverso, gestão de risco e segurança do paciente; descrever, a partir de relatos de enfermeiros, suas ações frente à ocorrência de evento adverso no cenário de seu trabalho; descrever as facilidades e dificuldades enfrentadas pelos enfermeiros para a notificação de evento adverso. Utilizou-se como metodologia um estudo de natureza exploratória com abordagem qualitativa, cujo cenário foi um hospital geral público situado em uma cidade da Zona da Mata mineira. Como referencial teórico, utilizaram-se estudos sobre segurança do paciente, gestão de riscos e notificação de incidentes e eventos adversos. A coleta de dados foi realizada através de entrevista semiestruturada, no período de novembro a dezembro de 2014, com 20 enfermeiros que exercem suas atividades laborais no referido serviço, e as respostas foram analisadas por meio da técnica de análise de conteúdo, emergindo três categorias temáticas: o saber do enfermeiro acerca de evento adverso, gestão de risco e segurança do paciente; o fazer do enfermeiro diante de um evento adverso; e facilidades e dificuldades encontradas pelos enfermeiros na notificação de evento adverso. Os resultados permitiram identificar que os enfermeiros dominam os temas evento adverso, gestão de riscos e segurança do paciente. Quanto à aplicabilidade das etapas do processo de notificação de eventos adversos, ficou evidente que a notificação desses eventos é uma prática cotidiana de enfermeiros, entretanto, nos depoimentos de alguns profissionais, observaram-se lacunas na notificação, que favorecem a subnotificação de eventos adversos. A análise temática do discurso dos sujeitos também permitiu expressar que, durante o processo de notificação dos eventos adversos, o enfermeiro se depara com aspectos que facilitam e dificultam este processo. Considerou-se que há atitudes profissionais favoráveis à notificação e também aquelas que interferem no sucesso do processo de notificação de eventos adversos, merecendo enfoque nos treinamentos, que podem ser utilizados como ferramenta para auxiliar na melhoria da segurança do paciente. / This study deals with risk management as a strategy for patient safety. Its object of study the process of notification of adverse events. The objectives were: to identify the knowledge of nurses about adverse events, risk management and patient safety; describe, starting from nurses reports, their actions toward the occurrence of adverse events in the setting of their work; to describe the advantages and difficulties faced by nurses to the adverse event notification. It was used as a study methodology exploratory qualitative approach, whose scenario was a public general hospital located in a city in Zona da Mata mineira. As a theoretical framework, we used studies of patient safety, risk management and reporting incidents and adverse events. Data collection was conducted through semi-structured interviews, from november to december 2014, with 20 nurses who perform their labor activities of the service, and the answers were analyzed using content analysis technique, emerging three thematic categories: knowledge of nurses about adverse events, risk management and patient safety; do the nurse before an adverse event; and facilities and difficulties encountered by nurses in adverse event notification. The results showed that nurses dominate the adverse event issues, risk management and patient safety. The applicability of the steps of adverse event reporting process, clarified that the notification of adverse events is a daily practice of nurses, however, the statements of some professionals, found gaps in the notification, which favor underreporting of adverse events. The subject of discourse thematic analysis also allowed to express that during the process of notification of adverse events, the nurse is faced with aspects that facilitate and hinder this process. There were considered to professional attitudes favorable to the notification and also those that affect the success of adverse event notification process, deserving focus on training, which can be used as a tool to assist in improving patient safety.

Objetivo: trata-se de revisão integrativa da literatura realizada com o objetivo de identificar os estudos primários que abordam os eventos adversos relacionados à sonda nasogástrica / nasoentérica (SNG/SNE) em pacientes adultos. Método: a busca foi realizada no mês de abril de 2017 nas bases de dados PubMed, CINAHL, LILACS, EMBASE e Scopus. Para realizar a busca foram utilizadas palavras-chave e encontradas 1.020 citações. Destas, 988 artigos foram excluídos a partir da leitura de títulos e resumos. Em seguida, procedeu-se a leitura, na íntegra, de 32 artigos, dos quais 12 foram excluídos. Logo, um total de 20 artigos foram incluídos no estudo. Foi realizada, também, busca manual nas referências dos artigos incluídos com o intuito de encontrar estudos que não foram recuperados anteriormente nas bases de dados supracitadas. Foram obtidos 84 artigos, dos quais 30 foram excluídos, a partir da leitura de títulos e resumos. Dos 54 artigos recuperados, quatro foram excluídos após leitura na íntegra e um artigo durante a extração dos dados. Resultados: para esta revisão integrativa, foram incluídos um total de 69 artigos. Os dados foram analisados e posteriormente classificados em duas categorias principais que evidenciaram os eventos adversos relacionados ao uso de SNG/SNE: incidentes mecânicos (complicações respiratórias, complicações no esôfago ou faringe, obstrução da sonda, perfuração intestinal, perfuração intracraniana e saque não planejado da sonda) e outros incidentes (lesão por pressão relacionada à fixação e conexão errada). A maior parte dos artigos recuperados foi incluída na subcategoria \"complicações respiratórias\" devido ao posicionamento inadequado da extremidade distal da sonda no trato respiratório, o que resultou em pneumotórax e/ou óbito. Outros eventos adversos estavam relacionados à obstrução da sonda, perda da mobilidade das cordas vocais, perfuração intestinal com consequente infecção, lesão na pele e mucosas, e queimadura corporal devido à desconexão. Conclusão: os resultados sintetizados nesta revisão permitem que os profissionais da saúde, especialmente os da enfermagem, reflitam sobre a segurança dos pacientes em uso de SNG/SNE e que repensem a maneira como as sondas estão sendo manuseadas na prática clínica / Objective: an integrative literature review was developed to identify the primary studies on the adverse events related to nasogastric / nasoenteral tubes (NGT/NET) in adult patients. Method: the search was undertaken in April 2017 in the databases PubMed, CINAHL, LILACS, EMBASE and Scopus. Keywords were used for the search and 1,020 citations were found. After reading titles and abstract, 988 of these articles were excluded. Next, 32 articles were fully read, 12 of which were excluded. Hence, in total, 20 articles were included in the study. In addition, a manual search was undertaken in the references of the included articles, aiming to find studies that had not been retrieved earlier in the abovementioned databases. Eighty-four articles were found, 30 of which were excluded after reading the titles and abstracts. Of the 54 retrieved articles, four were excluded after reading the full version and one article during the extraction of the data. Results: for this integrative review, in total, 69 articles were included. The data were analyzed and then classified in two main categories that evidenced the adverse events related to the use of NGT/NET: mechanic incidents (respiratory complications, esophageal or pharyngeal complications, tube obstruction, intestinal perforation, intracranial perforation and unplanned tube withdrawal) and other incidents (wrong connection and fixationrelated pressure ulcer). Most of the articles were included in the subcategory \"respiratory complications\" due to improper positioning of the distal end of the tube in the respiratory tract, resulting in pneumothorax and/or death. Other adverse events were related to tube obstruction, loss of vocal chord mobility, intestinal perforation with consequent infection, skin and mucous membrane ulcers, and body burns due to detachment. Conclusion: based on the results synthesized in this review, health professionals, especially in nursing, can reflect on the safety of patients using NGT/NET and reconsider the manipulation of the tubes in clinical practice

Cette recherche traite de la participation des patients à la sécurité des soins en radiothérapie, qui se définit comme les actions mises en œuvre par les patients pour réduire la probabilité d’erreurs médicales et/ou pour atténuer les effets des erreurs lorsqu’elles surviennent effectivement. La sécurité des patients en radiothérapie est devenue une priorité centrale pour les politiques publiques suite aux accidents récents survenus à Épinal, Toulouse ou Grenoble pour les plus emblématiques. Dans ce contexte, la participation des patients peut être un moyen d'amélioration de la sécurité des soins. L’objectif général de cette étude est de comprendre la dynamique constructive des capabilités des patients dans la coproduction d’un soin sûr et efficace. Les capabilités des patients se définissent comme les contributions réelles faites par ces derniers et visant à assurer la sécurité et l'efficacité des soins.L'étude est menée dans les services de radiothérapie d’un hôpital et d'un centre de lutte contre le cancer. Plusieurs méthodes ont été combinées pour analyser l'activité de travail des manipulateurs, des patients et de l’activité conjointe entre ces deux partenaires : des observations des séances de traitement, des entretiens semi- directifs avec des manipulateurs et des patients, des auto- et allo -confrontations avec des manipulateurs et des entretiens d'explicitation avec des patients.Les résultats décrivent les contributions effectives mises en œuvre par les patients, et montrent que la coopération du patient agit comme une barrière de sécurité supplémentaire qui renforce la sécurité et l'efficacité du traitement. L'environnement et la durée de radiothérapie (traitement répétitif sur plusieurs semaines) sont des ressources externes qui fournissent une opportunité créative pour le patient d’apprendre de la situation et de l'évaluer en observant ce qui se passe. L'étude s’attache également à analyser les facteurs qui permettent (facteurs dits « positifs ») ou au contraire empêchent (facteurs dits « négatifs ») de convertir les capacités des patients en capabilités, c’est-à-dire en contributions effectives. Les facteurs de conversion positifs sont relatifs aux patients (connaissance des risques associés aux soins, motivation personnelle), au collectif manipulateur-patient (objectif commun, synchronisation cognitive, synchronisation opératoire) et aux manipulateurs (construction d’une relation de confiance, encouragement et renforcement positif). Cependant, les capabilités des patients ne sont pas toujours optimisées et les fortes pressions temporelles rencontrées par les manipulateurs dans leur pratique peuvent empêcher leur développement.Cette étude a permis de montrer qu’il y a une volonté conjointe des professionnels et des patients d’aller ensemble vers une meilleure coopération. Elle montre également que la coopération du patient est une nécessité qui reste encore méconnue et sous-exploitée, alors qu’elle permettrait probablement de réduire le nombre de situations et des comportements à risques des patients. Cette participation active, si elle ne doit en aucun cas être exigée et être une source d’anxiété supplémentaire pour le patient, mérite d’être développée et encouragée. / This research deals with patient participation to patient safety, which can be defined as the actions taken by patients to reduce the likelihood of medical errors and / or mitigate the effects of errors when they do occur. Patient safety in radiotherapy has become a central priority for public policies further to the recent accidents arisen at Épinal, Toulouse and Grenoble for the most symbolic. In this context, patient participation may be a way of improvement of patient safety. The general objective of this study is to understand the constructive dynamics of patient capabilities in the co-production of a safe and effective care. Patient capabilities are defined as the actual contributions made by patients to ensure the safety and effective of care.The study was conducted in the radiotherapy departments of a public hospital and of a cancer center. Several methods have been combined to analyze the work activity of radiographers, of patients and of joint activity between the two partners : observations of treatment sessions, semi-structured interviews with manipulators and patients, self- and allo-confrontations with radiographers and elicitation interviews with patients.The results describe the actual contributions carried out by patients and show that patient cooperation acts as an additional safety barrier for patient safety. The environment of care and the duration of radiotherapy (repetitive and long treatment) constitute external resources, which provide a creative opportunity for the patient to learn from the situation and to evaluate it by observing what happens. The study also attempts to analyze the factors that allow ("positive" factors) or prevent ("negative" factors) patient capacities to become capabilities, i.e. actual contributions. The positive conversion factors are relative to the patients (knowledge of risks associated to care, personal motivation), to the collective (common objective, cognitive synchronization, operative synchronization) and to radiographers (construction of a trust relationship, encouragement and positive strengthening). However, patient capabilities are not always optimized and the strong work-related temporal pressures can prevent their development.This study highlights that there is a common will of professionals and patients to go together towards a better cooperation. It also shows that patient cooperation is a necessity that remains still unknown and underexploited, while it would likely reduce the number of risky situations and patients’ risky behaviors. Even if this active participation should not be required and be an additional source of anxiety for the patient, it should be developed and encouraged.

Introduktion: I den perioperativa vården arbetar flera yrkeskategorier som ska samverka tillsammans på ett patientsäkert sätt. Kommunikation är en viktig del till att kunna arbeta patientsäkert. Enligt patientsäkerhetslagen är vårdgivare skyldiga att förebygga vårdskador där en fungerande kommunikation kan vara en del att upprätthålla patientsäkerheten. Tidigare forskning har visat att kommunikation i operationsteamet kan påverka patientsäkerheten både positivt och negativt. Syfte: Syftet var att beskriva det interprofessionella operationsteamets upplevelser av kommunikation för att främja patientens säkerhet inom perioperativ vård. Metod: En kvalitativ intervjustudie utfördes med hjälp av semistrukturerade intervjuer. Intervjuerna utfördes på tre sjukhus i Mellansverige. Totalt femton intervjuer utfördes. Fem olika yrkeskategorier intervjuades, med tre deltagare från varje kategori: operationssjuksköterskor, anestesisjuksköterskor, undersköterskor, anestesiläkare och operatörer. Totalt femton intervjuer utfördes. Intervjuerna analyserades utifrån kvalitativ innehållsanalys. Resultat: Analysen resulterade i ett övergripande tema och tre kategorier. Temat var: ”Strävan efter den goda kommunikationen”, där det interprofessionella operationsteamets upplevelser beskrevs utifrån följande kategorier: ”De personliga relationernas betydelse”, ”Individuella strategier” och ”Användandet av kommunikationshjälpmedel”. Konklusion: Studien visade att det interprofessionella teamet strävade efter en god kommunikation som främjar patienten säkerhet. Dock fanns det även svårigheter i att uppnå detta.

Hospitals today focus on creating a culture of patient safety and reducing error. Registered nurses are mandated by the American Nurses Association's Code of Ethics to advocate for the patient at all times and to act accountably to ensure patient safety. There is a paucity of literature relating to how nurses' values and ethical ideology may affect their decision to act accountably. This study tested two hypotheses. Hypothesis 1 predicted that registered nurses who demonstrated a low relativistic ethical ideology would score higher on a measure of professional values than would registered nurses who demonstrate a high relativistic ethical ideology. Hypothesis 2 predicted an order of ethical ideology (absolutists then exceptionists, subjectivists and situationists) in scores on a measure of accountability. A descriptive non experimental design was used. Registered nurses (n=215) employed on the west coast of Florida completed a demographic form, Ethical Position Questionnaire (EPQ), Nurses Professional Values Scale Revised (NPVSR) and an investigator developed accountability instrument. A median split on the scores of the relativism and idealism scales on the EPQ formed the four groups of ethical ideology; absolutists, exceptionists, subjectivists and situationists. The accountability instrument consisted of 2 hypothetical clinical vignettes involving a late antibiotic administration. Using a Likert type scale, the participants answered three questions regarding how likely they would be to record the actual time of medication administration, call the physician and complete an incident report. Hypothesis I was not supported. Idealism (p=.001) not relativism had a significant effect on professional values. Hypothesis II was not supported. Absolutists scored highest on measures of accountability followed by exceptionists, situationists and subjectivists. When controlling for age, idealism not relativism had a significant effect on completing an incident report (p = .03). This is the first study to examine the effect of ethical ideology on professional values and a registered nurse's intention to act accountably. Previous studies described values held but did not link the descriptions to intentions to act. The information may be useful to hospitals as they build a culture of patient safety and develop a workforce that is accountable for its actions and decisions.

Bakgrund: Kommunikation är en nyckelfaktor för att kunna bedriva en säker och tillfredsställande vård. Vårdteamet består av flera olika professioner som behöver kommunicera för att uppnå satta mål. Av alla vårdskador är 70% orsakade på grund av bristande kommunikation. För att öka patientsäkerheten krävs det att vårdteamet har rutiner för att säkerställa att patientinformation överförs på ett säkert sätt. Inte minst mellan läkare och sjuksköterska krävs ett säkert kommunikationssystem eftersom professionerna samarbetar kontinuerligt. Syfte: Att belysa sjuksköterskors erfarenheter av interprofessionell kommunikation med läkare och dess betydelse för patientsäkerheten. Metod: Litteraturstudie baserad på tio vetenskapliga artiklar med kvalitativ ansats som granskats, analyserats och sammanställts till ett resultat. Resultat: Sju teman har framställts i resultatet bestående av “Roller”, “Tidsbrist”, “Förminskning”, “Anpassad kommunikation”, “Brist på information”, “Följder för patienten av bristande kommunikation” och “Teamarbete”. Konklusion: Sjuksköterskor upplever att deras kunskaper inte tas på allvar av läkarna. När läkarna undanhåller information om patienten upplevs frustration. De anser att en god relation till läkaren gynnar kommunikationen. För att förmedla information till läkarna krävs det att sjuksköterskrona anpassar sin kommunikationsstil beroende på specifik läkare och situation. / Background: Communication is a key factor to be able to provide safe and satisfactory care. The healthcare team consists of multiple professions who need to communicate to achieve their goals. 70% of all instances where the patient comes to harm in healthcare is because of communication errors. To increase the patient safety the healthcare team needs routines to ensure that patient information is transferred between the professions in a safe manner. Especially between the nurse and the physician the communication needs to function since the two professions corporate continuously. Aim: To examine nurses experiences of communication with physicians and the impact on patient safety. Methods: A literature review based on ten scientific articles with qualitative data that has been reviewed, analysed and compiled to a result. Results: Seven themes were produced in the results consisting of “Roles”, “Lack of time”, “Diminishing”, “Adapted communication”, “Lack of information”, “Consequences for the patient because of lack in communication” and “Teamwork”. Conclusion: The nurses experience that their knowledge is not taken seriously by the physicians. When the physicians are withholding information, the nurses feel frustration. They believe that a good relation with the physician improves the communication. To mediate information to the physicians the nurses sometimes need to adapt their communication style depending on which physician they are communicating with.

Bakgrund: Enligt Socialstyrelsens drabbas ca 110 000 patienter eller 8% av alla i den somatiska sjukhusvården av en vårdskada. En vårdskada är en undvikbar skada och patientsäkerhet är då att skydda patienten mot denna skada. En operationsavdelning är en komplex enhet med högteknologisk utrustning där många specialiteter och yrkeskategorier ska samordnas och arbeta i team för att patienten ska få en säker vård. Operationssjuksköterskan ska arbeta för en god och patientsäker perioperativ omvårdnad. Kärnan i operationssjuksköterskans omvårdnadsarbete är att säkerställa patientens säkerhet under operation och att arbeta förebyggande genom att tänka på allt som kan gå fel under en operation. Men vad som tillhör operationssjuksköterskans ansvarsområde och hur vederbörande kan säkerställa patientsäkerhet inom perioperativ omvårdnad behöver belysas och analyseras bättre.Syfte: Att belysa operationssjuksköterskans uppfattning om patientsäkerhet inom perioperativ omvårdnad i en svensk kontext.Metod: Kvalitativa semistrukturerade intervjuer genomfördes med 14 operationssjuksköterskor på ett mellanstort sjukhus i Södra Sverige. Intervjuernas innehåll analyserades med innehållsanalys.Resultat: Följande kategorier framkom i resultatet; Klinisk kompetens, Kommunikation, Vårdmiljö och Kompetensutveckling med elva underkategorier. Dessa kategorier reflekterade hur operationssjuksköterskorna uppfattade patientsäkerhet i förhållande till sin roll och ansvarsområden inom den perioperativa omvårdnaden.Slutsats: Resultatet indikerar att operationssjuksköterskan uppfattar att det huvudsakliga ansvarsområdet inom perioperativ omvårdnad är hygien och att bevara steriliteten och inom detta område försöker arbeta för att förhindra vårdskador och ge patienten en säker vård. Det finns dock omständigheter i organisationen på operationsavdelningen, i teamet och bristande respekt för operationssjuksköterskans kompetens som försvårar det arbetet. / Background: The National Board of Health and Welfare estimates that 110 000 patients or 8% of all patients in the somatic hospital care are affected by health care errors. A health care error is an avoidable damage and patient safety are defined to protect patient against damage. An operation theatre is a complex environment with advanced technical equipment. Interdisciplinary groups of health professionals work together in teams to deliver safe care for the patients. The operating theatre nurse shall work to give the patient safe perioperative nursing. The core of their work is to ensure patient safety during surgery, managing risks and preventing harm. However, to analyze and illuminate the responsibility of the operating theatre nurses work to secure patient safety during perioperative nursing seems to be scarcely investigated.Aim: The aim of this study was to illuminate the operating theatre nurses perceptions of patient safety in perioperative nursing in a Swedish context.Method: Qualitative semi structured interviews were conducted with 14 operating theatre nurses in a hospital in the South of Sweden. The data was analyzed using content analysis.Results: These categories were identified in the results; clinical competence, communication, care environment and skills development with eleven subcategories. These categories reflected how the operating theatre nurses perceived patient safety related to their role and responsibility in perioperative nursing.Conclusion: The result indicates that these operating theatre nurse perceive that the main responsibility in perioperative nursing is hygiene and to preserve sterility. Furthermore, work to prevent health care error and to give the patient safe care. There are circumstances in the organization of the operation theatre, in the team and lack of respect for the operating theatre nurses competence that complicates that work.

Bakgrund. Primärvården expanderar globalt och genomgår en förändring. Tillgänglighet prioriteras vilket har lett till en ökning av triage via telefonrådgivning och drop-in mottagningar.  Syftet med litteraturstudien var att undersöka för- och nackdelar med triage i primärvården relaterat till patientsäkerhet. Metod. En integrativ litteraturstudie med induktiv ansats. Mixad metod med både kvalitativa och kvantitativa artiklar användes och konvergent parallell design användes för att analysera artiklarna. Huvudresultat. Triage i primärvården bedömdes vara patientsäkert. Sjuksköterskor hade en god kommunikationsförmåga som bidrog till ökad patientsäkerhet. Däremot identifierades flertalet faktorer som riskerade att hota patientsäkerheten. Nackdelar vid triage via telefonrådgivning som uppmärksammades var bland annat beslutsstödsystemets brister och bristande kommunikationskunskaper hos sjuksköterskorna. Drop in-mottagningar behövde utvecklas men ansågs dock generellt främja patientsäkerheten. Vidare utbildning inom triage och kommunikation önskades för att säkerställa patientsäkerheten. Slutsats. Triage i primärvården via telefonrådgivning är fördelaktigt för patientsäkerheten. Litteraturstudiens resultat antyder även att triage vid drop in-mottagningar är fördelaktigt för patientsäkerheten, men ytterligare studier inom området krävs för att kunna undersöka om detta resultat reflekterar verkligheten. Sjuksköterskors kommunikationsförmåga kan utgöra både för- och nackdelar med triage i primärvården i förhållande till för patientsäkerheten, beroende på om kommunikationsförmågan är god eller bristande. Ett antal faktorer identifieras som riskerar att hota patientsäkerheten. / Background. Primary care is expanding globally and undergoing change. Accessibility is a priority, which has led to an increase in triage via telephone counseling and walk-in centres.  The purpose of this literature review was to examine advantages and disadvantages with triage in primary health care related to patient safety. The Design was an integrative literature review with an inductive approach. A mixed method with both qualitative and quantitative articles were used. Convergent parallel design was used to analyze the articles. Main findings. Triage in primary health care was judged to be safe for patients. Registered nurses had good communication skills that contributed to increased patient safety. However multiple factors that risked threatening patient safety were identified. Disadvantages identified in telephone triage were the flaws in the computerized decision support system and inadequacies in nurse’s communication skills among others. The walk-in centers needed to evolve but were considered to promote patient safety. Further education in triage and communication was requested to ensure patient safety. Conclusion. Triage in primary healthcare via telephone counseling is beneficial for patient safety. The results of the literature study also suggest that triage at walk-in centers is beneficial for patient safety, but further research is required to be able to investigate whether this result reflects reality. Registered nurses' communication skills can constitute both advantages and disadvantages of triage in primary health care in relation to patient safety, depending on whether the communication skills are good or lacking. Several factors are identified that risk threatening patient safety.

I Sverige drabbas cirka 100 000 patienter av vårdrelaterade skador. Systematisk kommunikationsöverföring mellan vårdpersonal är nödvändig för patientsäkerheten och god vård. Syftet är att undersöka om färre vårdskador uppstår vid systematisk rapportering utifrån standardiserade kommunikationsverktyg. En litteraturöversikt baserad på kvantitativa artiklar genomfördes. Det övergripande resultatet visade att det finns faktorer som påverkar hur kommunikationen förs fram. Resultatet visade delvis att antal vårddagar och vårdrelaterade skador reducerades vid användning av ett elektroniskt kommunikationsverktyg. De undersökta studierna gav ingen enhetlig evidens för sambandet färre vårdskador vid användning av ett standardiserat kommunikationsverktyg. Det går inte att dra någon slutsats om brist på systematisk kommunikationsöverföring bidrar till fler vårdskador då det inte finns tillräckligt med studier som undersöker detta. / In Sweden, approximately 100,000 patients suffer from health-related injuries. Systematic communication between healthcare professionals is essential for patient safety and good care. The purpose of this literature review is to investigate whether fewer health injuries occur in systematic reportering on the basis of standardized communication tools. A literature review based on quantitative articles was conducted. The overall result showed that there are factors that affect how communication is progressed. The results partly showed that the number of care days and care-related injuries was reduced when using an electronic communication tool. The analyzed articles did not provide a uniform evidence for the association of fewer health injuries when using a standardized communication tool. It is not possible to conclude that a lack of systematic communication transmission contributes to more health damage as there are insufficient studies examining this.

Bakgrund: Överlämnandet av patientansvaret från en vårdgivare till en annan är ett känt och återkommande riskmoment som påverkar kvaliteten och säkerheten inom vården. Tidigare forskning gällande anestesisjuksköterskans postoperativa överrapportering är begränsad. Syfte: Syftet var att identifiera faktorer som påverkar patientsäkerheten vid postoperativ överrapportering. Metod: En strukturerad litteraturstudie där 16 vetenskapliga artiklar analyserats utifrån Bettany-Saltikov och McSherrys stegmodell (2016). Resultat: Resultatet beskriver fyra kategorier: tillgång till information, variationer i arbetssätt, det professionella samspelet samt miljöfaktorers påverkan. Tillsammans beskriver de olika faktorer som påverkar patientsäkerheten vid postoperativ överrapportering. Slutsats: Studien pekar på ett samband mellan kvaliteten på överrapporteringen och patientsäkerheten. Anestesisjuksköterskan lämnar över patienter i särskilt utsatta situationer och måste därför vara extra uppmärksam på att korrekt och komplett information lämnas över samt att mottagaren har förstått det som sagts. Anestesisjuksköterskan kan bidra till en ökad patientsäkerhet genom att skapa rätt förutsättningar för säker överrapportering med ett organiserat arbetssätt, god förberedelse och genom att lämna rapport som är relevant för mottagaren. / Background: The transfer of patient responsibility from one healthcare provider to another is a known risk factor that continues to affect the quality and safety of patient care. Previous research on the nurse anesthetist’s postoperative patient handover is limited. Aim: To identify factors that affect patient safety in postoperative patient handover. Method: A systematic literature review where 16 articles were analyzed according to Bettany-Saltikov and McSherry’s nine step approach (2016). Results: The result describes four categories: access to information, variations in work procedures, professional interaction and the impact of environmental factors. Conclusion: According to this review there is a connection between the quality of the handover and patient safety. The nurse anesthetist takes care of patients in particularly vulnerable situations and must pay extra attention to providing accurate and complete information. The nurse anesthetist can contribute to improved patient safety by creating good conditions for safe handovers by being well organized, well prepared as well as ensuring the information is relevant for the recipient.