Segurança do paciente em diagnóstico por imagem: proposta para mitigar falhas na identificação

Abstract

BACKGROUND: The Brazilian Ministry of Health established the National Patient Safety Program in 2013, aiming to prevent and reduce incidents in healthcare services. As part of this program, the creation of the Patient Safety Nucleus (PSN) became mandatory. However, several healthcare institutions in Brazil are yet to implement their PSN. In the State of Amazonas (AM), as of January 2023, only 98 PSNs have been established, accounting for approximately 8% of healthcare organizations in the region. It is worth noting that AM frequently experiences identification errors, with patient identification failure and documentation failure being the most common issues in radiology from September 2019 to August 2020. OBJECTIVES: The objective of this research is twofold: firstly, to establish an electronic notification system within an imaging clinic in Manaus; and secondly, to develop a proposal for ensuring accurate patient identification during imaging exams. METHOD: Design Thinking, as an approach to address complex problems. The following sequential steps were undertaken: 1) Discovery: The problem was identified through a questionnaire on safety culture, process mapping, and event notification. 2) Summary: The Patient Safety Nucleus was registered with the health surveillance agency, and an action plan was developed. 3) Ideation: An electronic notification model was created to address the identified issues. 4) Prototyping: The system underwent validation, and successful strategies were standardized. RESULTS: Over the course of 18 months, a total of 608 events were reported, comprising near miss (68,6%, n=417), events without harm (28,1%, n=171) and adverse events (3,3% (n=20). The most frequently reported isolated error was related to patient name, accounting for 20,6% (n=125) of the total errors. Categorized by type, document errors represented 44,2% (n=269) and patient identification errors accounted for 29,4% (n=179). The total number of events corresponded to 0,36% of all performed exams, with adverse events representing 0,01% of the total. The highest percentages of errors were observed in MRI scans (0,88%, n=227), CT scans (0,67%, n=122) and x-rays (0,49% n=101). Following the implementation of healthcare policies, there was a reduction in events related to patient identification from 13,6% to 4,8%, a decrease in the overall occurrence of type, side and site errors from 21,2% to 7,6% and a decline in procedural error from 28,8% to 12,4%. CONCLUSIONS: The combined implementation of an electronic notification system, process improvement measures, and training resulted in reduction of 64,7% in patient identification errors. Additionally, there was a reduction of 64,1% in the occurrence of type, side and site errors, and a decrease of 56,9% in procedural errors.