Impact Analysis of Patient Safety Center Deployment in Brazilian Public Hospital Jaqueline Tonelotto, Carla R. Y. Kobayashi, Taís A. Z. Vassi, Selma M. Costa,

João G. Negrão, Monica Carneiro, José Kleber Kobol Machado

MUNICIPAL HOSPITAL UNIVERSITY OF SÃO BERNARDO DO CAMPO

ABSTRACT

The implementation of patient safety center at the Municipal Hospital University of São Bernardo do Campo, São Paulo, Brazil ocurred in May, 2014.This team is composed by a doctor, a nurse and a administrative officer. The hospital performs assistance to women and has a capacity of 140 beds distributed between maternity, neonatal ICU, pathological nursery, adult ICU and gynecology.

Our objectve was to assess the impact of a team to advise on patient safety and increase the culture of notifications of inadequate processes of work with direct impact on patient care.

METHODS

Use of annual indicators of number of notifications and solving the years 2013, preimplantation of security team, compared with 2014 with the implementation of patient safety team.

RESULTS

In 2013 were performed 170 failure notifications work process with conclusion of 40% of cases, 52% pending resolution and 8% of cases in progress. In 2014 compute 581 notifications in 91% completed, 8 % pending resolution and 1% of cases in progress. The units that required further attention were the pharmacy/warehouse and the external laboratory. In 2014 patient safety team analyzed 3 sentinel events with harm to the patient: 2 pressure ulcers and 1 medication error in the neonatal unit. After the analysis of these cases the team held protocol review actions, staff training in pressure ulcer prevention and the10 steps drug administration.

IN PROGRESS

1%

NOTIFICATIONS,2014 n=581 PENDING

RESOLUTION 8%

CONCLUSION 91%

CONCLUSION

IN PROGRESS

PENDING RESOLUTION

Impact Analysis of Patient Safety Center Deployment in Brazilian Public Hospital

Jaqueline Tonelotto, Carla R. Y. Kobayashi, Taís A. Z. Vassi, Selma M. Costa,

João G. Negrão, Monica Carneiro, José Kleber Kobol Machado MUNICIPAL HOSPITAL UNIVERSITY OF SÃO BERNARDO DO CAMPO

RESULTS CONTINUED CONCLUSIONS

REFERENCES

We can affirm that the creation of this team encouraged the notification of inadequacies and the team acted in the adequacy of these complaints with improved work process, protocol review, intensification of continuing education with a consequent increase in the safety of hospitalized patients.

• Annual indicators of Municipal Hospital University of São Bernardo do Campo

SERVIÇO MÉDICO 5% NEONATAL ICU 3%

NUTRITION 3%

LABORATORY 10%

HYGIENE AND CLEANING

4%

NURSING MANAGEMENT

5%

UNIT MANAGEMENT 5%

PHARMACY 28% BUILDING

ENGINEERING 4%

CLINICAL ENGINEERING

3%

TRANSPORTATION 2%

LINEN 1%

RADIOLOGY 2%

CSE 1%

SURGERY CENTER 1%

WAREHOUSE 3%

ANOTHER UNITS 19%

DISTRIBUTION OF ERROR NOTIFICATIONS BY NOTIFIED UNITS, 2014