Análise de incidentes na atenção primária à saúde do distrito sanitário nordeste de Belo Horizonte

Abstract

Introduction: The patient´s safety is widely studied in health services, in the hospital environment, and it has gained prominence in the scope of Primary Health Care (PHC) due to the large amount of users served, procedures performed, and the progressive increase in care complexity in this área and the attention level. An incident is an event that, resulting from an intentional act or not, can cause unnecessary harm to the user, and results in an adverse event within the scope of a health service. Objective: To analyze Patient Safety incidents in Primary Health Care in the Northeast Sanitary District of Belo Horizonte, from the perspective of managers and workers of the Family Health Strategy. Method: This is a descriptive research, with a mixed approach, with a concomitant triangulation strategy, which took place in 20 Health Centers (HCs) in the Northeast Sanitary District of Belo Horizonte. A total of 100 professionals were invited, selected by arbitrary means. Data collection was carried out between November and December 2021, through the application of the Primary Care International Study of Medical Errors questionnaire. Quantitative data were tabulated and analyzed using SPSS software, version 25. Qualitative data were evaluated using Bardin's content analysis. Results: Eighty professionals participated in the study, who performed 112 notifications within a 30-day period. Most of them were women, aged between 35 and 44 years, with more than 10 years of experience in PHC. The incidents occurred especially in the administrative sector and 82.7% of the errors hit a particular user. In 49.4% of cases, the affected user was not harmed. As for the error classification, 81.5% of the incidents were related to the work process and 18.5% to errors in knowledge and skills. Most of the errors related to the work process were related to communication errors (27.2%), administrative service errors (24.7%), and treatment errors (19.8%). Regarding incidents related to knowledge and skills, it was identified that the most frequent errors were related to the execution of a clinical task (14.8%), such as the application of vaccines and medications. The users affected by the incidents were predominantly women that the team already knew, with an average age of 50.8 years and who had chronic diseases. Vulnerable individuals were 6.66 times more likely to have an incident with damage. As incident prevention factors were cited improved communication during the work process, greater attention to following existing flows, prescriptions and routines, organization of the work process, training of professionals in addition to the guarantee of human and material resources. Final considerations: Identifying the error is an important measure to increase the effectiveness of health care in organizations, as it gathers information to support the analysis and correction of directions in the reduction of incidents. Primary Health Care Centers must address the error from an individual and systemic perspective. The development of an incident notification tool to be used as a technical support product for Health Center teams, in the search for quality of care in Primary Health Care, provides an important tool to understand the magnitude of the problem at this level of care, in addition to contributing to the improvement of assistance.