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Dimension prescribed and realyity of practices of health professionals in the context of patient safety


Andreia Guerra SimanI; Maria José Menezes BritoII

I Nurse. PhD in Nursing. Department of Medicine and Nursing: Federal University of Viçosa. Viçosa, Minas Gerais, Brazil. E-mail:
II Nurse. Post-doctor. Department of Applied Nursing. Federal University of Minas Gerais. Belo Horizonte, Minas Gerais, Brazil. E-mail:
III The study is a result from the PhD Dissertation "Practices of health professionals in the implementation of the patient safety program: between the prescribed and the real". The authors acknowledge the Graduate Program in Nursing of the Federal University of Minas Gerais, to CNPq, FAPEMIG and CAPES for funding the research.





Objective: to understand the prescribed and real dimensions of daily patient safety practice by health personnel. Method: the participants in this qualitative case study were 31 members of the Patient Safety Center and the nursing staff at a teaching hospital in Minas Gerais, Brazil. Data collected in 2015 by scripted, semi-structured interview, were complemented by observation and secondary data. Data triangulation and content analysis were used. The project was approved by the research ethics committee (CAAE 44109015.0.0000.5149). Results: changes were more evident in the prescriptive conception (introduction of the center, patient safety plan and protocols). Patient safety was not prioritized as a strategic guideline at the hospital, where team training and evaluation of actions were lacking. Conclusion: patient safety was more evident as a prescription. The work being done does not correspond exactly to what is proposed by the rules and protocols.

Descriptors: Patient safety; hospitals; quality management; nursing services.




The objective of this study is the daily practices of health professionals in the context of patient safety, the prescribed and actual dimensions in a teaching hospital in Minas Gerais.

In view of the magnitude of adverse events in Brazil, the National Patient Safety Program was instituted in 20131 and a resolution was published to establish actions to promote patient safety and improve the quality of health services2. Each service must institute a Patient Safety Nucleus (PSN) and provide human, financial and material resources, besides equipment, supplies.

In this sense, health professionals and managers need to implement and master tools to ensure that all stages of a process are met and, consequently, failures are avoided. However, how has the Patient Safety Nucleus been implemented? Has this strategy been enough to change the practices of professionals? Do the legislation, the control, the organization, the strategic norms, the protocols guarantee the change in the daily practices of professionals?

Standardizations may not adequately ensure patient safety, and there is evidence that more efforts are needed to improve processes within health institutions with respect to safety3. Shortcomings are assumed to be present in the institution of protocols and in the effective implementation and evaluation of the process to subsidize managerial and care actions. One of these gaps is the distance between the prescribed dimensions of planning of patient safety practices in the hospital and the real work of the professionals. In this perspective, managers and administrators of institutions should lower the barriers and pool efforts to develop a safety culture through information and learning.

The objective of this study was to understand the prescribed and actual dimensions of the practices of health professionals in the context of implementation of patient safety.



Initiatives focused on patient safety began with the publication of the report To err is human, which pointed out that up to 98,000 deaths per year in the United States could be prevented and were the result of medical errors4. This report generated a global warning to health institutions.

The International Patient Safety Classification relates patient safety to the reduction of risk of injuries or lesions associated with health care, within a minimum acceptance5.

In this study, the following definitions were adopted: risk is the probability of an accident to occur; error is a mistake, an action that occurs out of the plan or incorrect application of the plan; adverse event (AE) is any damage or injury caused to the patient by an intervention of the health team5.

Surveys have shown that the daily practices of health professionals have been marked by high error rates, reports of injuries in patients, flaws in hospital care systems, permanent damages and deaths. Inadequate, insecure and negligent practices affect one in ten patients on average in developed countries4;6,7.

In the present study, we opted to work with the concept of practice in the broadest sense, as social practices within the praxeological perspective. This is an approach that can group analyses at management, institutional, organizational and behavioral levels allowing the intersections with human actions8.



This study has a qualitative approach whose design was case report, a research strategy that aims to analyze a social unit to answer how and why phenomena occur. The nature of the problem and the details of the phenomenon to be analyzed justify the choice for case report9.

The choice of the study scenario took into account that the selected place is a hospital that is zealous for the quality of service and patient safety and it is a member of the Sentinela Hospital Network, which means that it has a risk management committee. It is a philanthropic hospital linked to a teaching hospital located in the Zona da Mata ("forest area") of Minas Gerais, Brazil. It has 116 beds and an average of 5,232 patients/day every month. It is a reference service of a micro-region composed of nine municipalities and has six hospitalization wards.

The participants of the research were members of the PSN and the nursing team of the hospitalization ward of the medical and surgical clinic. The inclusion criterion was having at least one year of work in this sector. The choice for interviewing the team of the hospitalization ward was based on the results of a survey whose objective was to evaluate the incidence of adverse events in hospitals in Brazil. The results of this survey showed that the nursing ward was the place where adverse events were most frequent (48.5%)10. The choice of PSN professionals came from the understanding that they are the ones who manage and prescribe actions to achieve patient safety.

The PSN was composed of 14 members and all were invited to participate, but as two professionals were on medical leave, reducing the sample to 12 subjects. The nurses of the hospitalization ward corresponded to a group of nine professionals, of the night and day shift, and two did not meet the inclusion criteria, reducing the group to seven participants. As for the nursing technicians, the saturation criterion was used. This means that interviews are interrupted when the collected data become repetitive and redundant. This occurred in the 12th interview. In total, 31 professionals participated in the study.

Data collection of primary and secondary data took place from May to November 2015. Secondary data were obtained through documental research (reports, protocols, indicators and quality records and PSN action plan) through which it was possible to retrieve the prescribed sources. Primary data were collected through interviews with aid of a semi-structured script and through observation with a field journal record. Observations and interviews promoted the rescue of real sources.

The interviews ranged from 10 to 100 minutes and were recorded and transcribed verbatim. They were numbered according to the sequence in which they occurred and coded with the acronym PSN, N (nurse) and NT (nursing technician). The questions sought to understand aspects such as knowledge about patient safety, assessment of patient safety in the institution, practices and notifications to achieve safety, difficulties and facilities to achieve international goals and activities of the Nucleus.

Content analysis, and specifically the thematic category, was used to treat the data. Thematic content analysis consists of a set of communication analysis techniques conducted around three chronological poles: pre-analysis, material exploration and treatment of results11. According to systematic procedures, codification or registration units were defined and then grouped into two categories.

All participants signed the Informed Consent Term, in compliance with Resolution 466/12 of the Ministry of Health, and the project was approved by the Research Ethics Committee of the Hospital and by the Research Ethics Committee of the Federal University of Minas Gerais, CAEE nº 44109015.0.0000.5149.



The two categories of the study are analyzed below.

History of the implementation of the Patient Safety Nucleus

This category was mainly based on the documentary analysis and field observations. In 2010, the hospital started the Hospital Accreditation Process with the goal of obtaining the Accreditation certificate, level 1 of the National Accreditation Organization (NAO). A quality sector was organized and, in 2010, a diagnostic visit from a Certificated Accreditation Institution was requested. At the time, a report was issued suggesting various modifications in the framework of structures, processes and results. However, the institution faced some difficulties that made it impossible to continue the process.

Hospital accreditation is one of the strategies used to improve the quality of services and minimize the occurrence of errors. Institutions need to comply with standards that focus on patient safety, standardization of procedures, changes in work management, creation of risk management, protocols and indicators12,13.

Safety is considered one of the dimensions of quality1. These are inseparable; health services that minimize the risk of harm to patients (safety) are increasing the quality of the care provided14.

In 2012, the institution was accredited in the Sentinela Hospital Network of Brazil, coordinated by the National Health Surveillance Agency. This network aims to prevent risks associated with the consumption of products subject to sanitary surveillance. Hospitals linked to the network need to notify and monitor adverse events and technical complaints of products, and promote measures to reduce them. Participation is voluntary and the main purpose is to report adverse events15.

The hospital had the Program for Strengthening and Improving the Quality of Hospitals (Pro-HOSP) of the Unified Health System (SUS), which had already required the creation of a risk management commission. The PSN, created in May 2013, was composed of Pro-HOSP members and other professionals. During this period, the risk in each sector was mapped and technical complaint notification sheets were created.

It should be emphasized that it is acceptable that the head of the health service employs the structure of existing committees, commissions, managers and coordinators or nuclei for the realization of the assignments of the nucleus2.

The PSN was appointed by the administrative director with nine nurses to represent all sectors; a nursing technician; a nutritionist; a reception coordinator; a maintenance coordinator; a pharmacist and an operational support manager. It is noteworthy that there was no representative of the medical class, which would be fundamental to comply with the principle of systematic dissemination of the safety culture. Furthermore, no related committees were identified as advisory members of the nucleus16.

Despite the creation of the nucleus, the institution maintained its system of notifications and the preventive and educational actions focused on technical complaints, and only in 2015 instituted the internal adverse events (AEs) notification form. The risk manager is the professional who updates the record of notifications in the National Health Surveillance Notification System (NOTIVISA). A study indicates that 50% of notifications of EAs and technical complaints come from the Sentinel Network15 .

According to RDC nº 36, the institution under study has developed a Patient Safety Plan (PSP), a document that identifies risk situations and describes the strategies and actions to achieve international safety goals, with a view to preventing and mitigating incidents2.

The study indicates that compliance with patient identification, application of the checklist for safe surgeries, and safety in drug administration, among others, represent an improvement in the processes in health institutions. In order to meet these requirements, an adaptation of several management and care processes is necessary, allowing not only the safety of patients but also of professionals17.

Some protocols were described, such as those for: prevention of falls and pressure ulcers; safe surgery; patient identification; hand hygiene; enteral and parenteral therapy; and administration of blood components. There was no protocol for administration of medications, what was justified by the absence of a clinical pharmacy. These findings are consistent with a study carried out with 14 risk managers, which pointed out that the least used initiatives for patient safety are those related to the control and prevention of AEs related to drugs. Clinical pharmacists are not yet a reality in Brazilian hospitals18.

Regarding the observation in the hospitalization ward, the six units are located from the second to the fifth floor. Posters and leaflets on patient safety produced by the Ministry of Health and a folder containing the Standard Operational Procedure (SOP) for notification of AEs were observed.

It was possible to observe that nursing technicians were busier and more overloaded than other professionals. Often the professionals were restless. There were many residents, places with a great circulation of people, and many professionals manipulating the medical records. The wards had patients with a wide variety of diagnostic and clinical conditions. It should be pointed out that this variety of clinical conditions may hinder the standardization of the conducts and the demand is generally higher than the capacity of the service to provide quality care19.

Regarding the work routine, disorganization in the workplace was identified; technicians made decisions about routines, schedules and divisions of tasks. Lack of organization in the service is one of the aspects commonly related to AEs20. Nursing technicians carried out patient hygiene and administration of medications. In some situations, the technicians would ask the opinion of the doctor. Nurses were seen to assume two sectors located on different floors, causing difficulty to their work.

There was little communication within the multiprofessional team. They used an administrative notebook, a shift of duty, and an internment board (conventional administrative instruments), but there seemed to be no planning and conduction of the work process. The actions of nurses were punctual and marked by attempts to implement the Systematization of Nursing Care (SNC). Gaps in knowledge and absence of actions based on the principles of quality and safety were identified. The nursing staff felt insecure due to a lack of human and material resources, and lack of equipment maintenance.

These findings refer to the practice of nurses of establishing personal relationships as an essential characteristic for achieving results, monitoring AEs, working for quality and improving safety and patient care. The importance of nurses to deal with problems in search of solutions for the improvement of the clinical practice, such as reviewing care processes, stands out21. It is necessary to include the study on leadership, training and continuing education with all the professionals involved in the process of patient care22,23.

Patient safety: from the imaginary to the real

The study revealed a distinction between the prescribed and the actual practice for achieving patient safety. Despite the fact that there is a well-structured nucleus within the prescribed scope, it is inferred that its concretization has not yet occurred, as if it were still in the imagination of its creators, or only as compliance with norms to gain approval in inspections.

The PSN is an instance of the institution that aims to disseminate the safety culture and analyze the reported incidents, identifying their causes and adopting prevention strategies2. However, some professionals were unaware of the existence of the Nucleus and its practices, which demonstrates that the Nucleus was formally implemented, but had little impact in the real scope:

I don't know. I did not even know that this Nucleus exists, to be honest. (THEC 21)

I don't know it in the institution. No one ever introduced me. Unless it was presented to some other nurse. (N3)

I do not know of any action specifically aimed at patient safety. It is not formally performed. (N1)

It should be noted that there is no direct contact between the members of the nucleus and other health professionals, and they are not recognized as leaders:

This week we had a problem, I scheduled the meeting with the two of them, and we managed to solve it. It was a notification I received and the girls were surprised. What are you doing here? The problem is between the two sectors and, as infection control nurse, I had nothing to do with that, but as risk manager, I had (PSN2).

During field observation and documentary analysis, it was possible to identify that the norms and records of the nucleus appeared in the prescriptive scope, but with timid actions and influenced the professional practice only in terms of small changes. Additional resources to improve patient safety in public hospitals is essential, as well as and prioritize it as a strategic guideline, as defined by the hospital leadership and administration24. However, the data in this study confirm the fact that the Brazilian scenario of hospitals is still based on cost reduction14. Promotion of patient safety and its development at all levels of the organization, as well as a direction to improvement actions on the part of leaders, are recommended22.

The participants were dissatisfied because there was no feedback from the top management after the analysis of AEs. Health organizations should measure their safety culture, give a feedback to the leadership and the staff in order to reduce risks and seek improvements22.

Therefore, the Nucleus must be operational and supported by management. There were several reports of falls. I just fill out the paper. Other more serious falls have happened. After I notify the event, I have not had any feedback. (N14)

Another aspect that shows the distance between the prescription and the reality was the fact that the members of the PSN were trained, but they did not multiply this knowledge by sharing it with other professionals. This confirms a disarticulation of the Nucleus with other professionals, causing discontinuity of the processes:

In the course we did, we had to present the knowledge for all professionals. It was in São Paulo, eight people founded the Nucleus. But what have we done? I think we should have come and pass it [the knowledge] to all employees. (PSN5)

Another thing we have tried to do is notify. I think there are a lot of people, most of the technicians, they do not know it. We know because we are the Nucleus. (PSN12)

Effective communication is a determinant factor for patient safety, as well as interdisciplinary work and diversity, sharing of knowledge, and adequate training and education to perform the functions are fundamental22.

Regarding the notification of AEs, this was done manually and in printed form. However, 58% of the participants in the survey were unaware of the process and did not have access to the notification form. Nursing technicians, in special, reported to be unaware of the existence of the form. Audits of AEs were performed almost always on the day of they occurred, but their implications were generally punitive and did not change the practice:

Patient falls never happened with me, or other event. There is one for venipuncture in the room, a printed document for that. But, it never happened to me. I've never seen another print. (N20)

Not that I know of. If there is any sheet there to notify, I'm not aware. (TECH21)

Knowing institutional risks is necessary to avoid them, and manage them25. However, a systemic approach to errors25 and an assessment based on indicators26 are needed.

Regarding the plan, it was observed that this did not contain actions and goals to achieve patient safety. No use of assessment tools or strategies to reduce AEs was seen:

I will be very honest, if there was an action plan, I don't remember how it was implemented. There are some protocols that I helped to prepare, but that was long ago, it was about pressure ulcer prevention, and I don't remember. (PSN 9)

I've seen a little about the internal rules, but a plan of action, no, this I haven't seen. (PSN10)

The data indicated that there was no collective construction of the plan and no multidisciplinary work, missing the opportunity to value the knowledge of each professional and making it difficult to disseminate and adhere to the proposals to improve care provision. The plan should bring monitoring activities for detection of problems and control of the maintenance of the improvements achieved14.

Another highlight, and one of the first results of the work of the PSN, is the safety protocols. Although the documentary analysis confirmed the existence of these protocols, the practices of professionals were isolated and carried out in personal basis. The professionals reported:

I try to do this informally. As there is not a formal way to do it, I try to check everything, I check if the medication is correct; if materials are correct; I guide the workers to make the correct checkup. (N1)

We do not have the protocol yet, but I think the boys can identify more clearly the issue of pharmacovigilance than the internal event. (PSN2)

The analysis of the data allows us to infer that the protocols were in the prescriptive plan of the institution, but unknown in the practice. It is emphasized that protocols and the SNC are processes that help standardize treatment, minimize error and promote patient safety27. The noncompliance with these protocols is a demonstration of lack of quality and safety. Their implantation improves the results of the treatment and the quality of the care, avoiding more serious damages28. The findings indicate that there is a need for greater technical-scientific investments and promotion of safety culture from the part of management, as similarly incentivized in a recent study29.

The findings presented here provide innovative contributions to a deeper understanding of the challenges present in public hospitals - the pursuit of a day-to-day practice focused on patient safety. The work done does not always correspond exactly to the prescribed plan, proposed by rules and protocols. Variability in human action is great and unpredictable when a task carried out, especially because the work is complex and cradled in human activity. The qualitative nature of this research and the absence of similar studies limit the comparison of results.



The study showed that transformations are more evident in prescriptive conceptions than in practice. An effective reorientation by the PSN is necessary for the adoption of patient safety practices, not only by the nursing team, but by all health professionals. The results indicate a long way to achieving the goals of the World Health Organization of patient safety.

Theoretically, the participants referred to practices based on international patient safety goals. However, the reality was beyond the recommendation. Such hard reality needs to be transformed with the support and involvement of management, effective performance of the Nucleus, and a proposal of continuing education.

Reducing risks involves the participation of all hospital sectors and not just the Nucleus. However, the Brazilian scenario is still based on cost reduction and there is no prioritization of patient safety. These are barriers that must be overcome to ensure a patient safety culture.

The main limitation of the research is a result of the methodology adopted: case studies do not allow generalizations. Thus, the reality here does not necessarily represent the reality of other institutions.



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Direitos autorais 2018 Andreia Guerra Siman, Maria José Menezes Brito

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