Segurança do paciente na atenção primária: identificação de incidente e desenvolvimento de proposta de protocolo para notificação

Abstract

Introduction: Patient safety has undergone increasing evolution and is directly related to the quality of health care. Primary Health Care has been gaining prominence in health care, being used in most of the places where care is being provided. With the increase in demand at this level of attention, the number of incidents in these services has increased, so in order to prevent and reduce risks and damages, it is necessary to know the characteristics of the incidents and to apply improvements to the Patient Safety Program Primary Care. Objectives: Identify incidents that interfere with patient safety in Primary Health Care in the Federal District. Method: Observational and descriptive study performed in eight Basic Health Units with Family Health Strategy in a Health Region of the Federal District. The questionnaire Primary Care International Study of Medical Errors adapted to the Brazilian context was applied to 20 physicians and 28 nurses who work in the Basic Health Units and who agreed to register in an anonymous and confidential way the incidents that occurred with the patients during three months. Results: There were incidents that reached the patient and caused damages in 47.1%, incidents that reached and did not cause damages in 37.3% and incidents that did not reach the patients in 15.6%. The minimum damage was the most prevalent with 15.7% and communication failure was the most observed contributing factor. Product developed: Proposed Protocol for notification of incidents in the Primary Health Care of the Federal District that will be sent for registration in the Standing Committee on Protocols of the State Department of Health of the Federal District. Conclusion: The study demonstrated the existence of incidents in Primary Health Care and produced information on patient safety and allowed the elaboration of a protocol to be used by the State Department of Health of the Federal District to promote improvements in the Patient Safety Program in Primary Health Care.