Gestão de incidentes em hospitais públicos do Distrito Federal: construção participativa dos formulários, protótipo e desenvolvimento de software

Abstract

Introduction: Patient safety has been approached in the health area with the objective of reducing the frequency of incidents that occur to patients, resulting from health care, the damage caused to them, as well as the high cost to the institutions (BRAZIL, 2013). The establishment of incident reporting and monitoring programs is part of the primary strategies of the World Health Organization and the Ministry of Health to promote safety, reduce incident occurrence and improve the quality of health services. In addition to broadening knowledge about care risks, it helps in incident management, points action planning and improves work processes. Objective: To develop a computerized information management system for reporting, investigating and monitoring health incidents. Method: Methodological research of the type of technology development, carried out in four stages: 1) Documentary analysis of primary and secondary sources related to forms, protocols, guidelines and legislation on incident notification systems, published in physical or electronic media in the years of 2005 to 2019, held from September to October 2018; 2) Construction of a medium fidelity prototype using the Pencil Project version 3.0.4 tool with the data and requirements to be incorporated into the system; 3) Deliberative dialogue held in two sessions, attended by 12 managers and coordinators of the Quality and Patient Safety Center of public hospitals in Distrito Federal, Brazil, held in November 2018; 4) Monitoring the development of the system, with the joint elaboration of the technical requirements of the software, definition of indicators and system functionalities. Results: 1) Creation of notification forms: with the categories of information and data to report an event; Investigation: with the list of contributing factors for the occurrence of the event; and Monitoring: through indicators. 2) Construction of the software prototype following the data flow, methods and instruments to operationalize the risk management process; 3) Development of the health incident management system. Developed Products: Article “Health Service Incident Monitoring Prototype: Innovation for Patient Safety” and Health Services Adverse Event Prevention Information System-IPES² developed through contracted technical staff. Conclusions: The incident management system can lead to advances in patient safety, based on the use of information as a substrate for knowledge production and action planning. In addition, forms can be used as a facilitating basis for people interested in the topic to develop, evolve or improve incident reporting systems. It is expected to contribute, with the generated products, to the reduction of the occurrence of incidents and consequently to promote the effective improvement of the services rendered in the hospitals of the Distrito Federal Health Department.