Eventos adversos decorrentes do processo de trabalho em enfermagem

Abstract

This research brings as its object of study the adverse events that triggered the opening of Disciplinary Ethical Processes and its relationship with the nursing work process. The occurrence of adverse events due to unsafe care is one of the top ten causes of death and disability in the world, and is considered a global health problem in which an unforeseen and undesirable incident in healthcare, results in unnecessary harm to the patient. It is estimated that in high-income countries, one in ten patients is harmed when receiving hospital care. The most harmful errors are related to diagnosis, prescription and use of medications. Therefore,the following research question was asked: „„ What are the characteristics of adverse events that triggered the opening of Disciplinary Ethical Processes and how are they related to the nursing work process? ‟‟ ‟‟ To answer this question, this study aimed to analyze the characteristics of adverse events that triggered the opening of Disciplinary Ethical Processes and to discuss their relationship with the nursing work process. This is a retrospective, exploratory-descriptive, cross-sectional, documentary study, with a qualitative approach, developed in the light of the referential of the patient safety culture. The final time frame established was from 2009 to 2017. Data were collected between February and October 2019, after approval by the Ethics Committee with protocol 02845418.0.0000.5013. 60 ethical processes in possession of the municipality were identified and of these seven were due to adverse events. Most of those involved in ethical processes are eight middle school professionals, followed by four higher level professionals. The analysis of adverse events revealed a predominance of cases that occurred in Primary Care Units. Most of them were related to skill, non-compliance with rules or norms and lack of knowledge of the technique. Given the complexity of health care, being aware of the amount of adverse events that generated ethical processes and the way they were conducted in their judgment serves as a contribution to assist in the weaknesses found in the common individual approach to error, which compromise the entire judgment process in the light of the Just Culture, and foster the culture of fear.