In recent years, Chinese government has made relevant policies to promote patientsafety, and different levels of medical institutions are organizing patientsafety activities in various forms. But the current medical environment is heavily influenced by traditional medical culture, and many traditional ideas and practices have not been transformed fundamentally. Thus, there is still a long way to go before realizing an active safety culture climate (Zhang, 2015). There are many factors affecting safety performance within the medical institutions, such as neglecting established procedures, focusing on speed rather than accuracy and in some cases even risk-taking practices being encouraged (Patankar, Brown, Sabin, & Peyton, 2015). Other factors include a lack of efficient communication between executives and staff, poor coordination between departments, high workload and work stress of nurses, postponed report on medical errors due to false thinking and frequent patientsafetyincidents (Ren, 2011). In 2013, an investigation on nursing staff’s awareness ofpatientsafety culture was carried out, which indicated that improvements should be made in terms of frequency of adverse events reporting, non-punitive reaction to errors and nursing staff allocation (Li, et al., 2014).
As it is not directly linked to high-tech proce- dures, PHC may be thought of as a safe and se- cure environment. It is known that Adverse Events (AEs), defined as incidents that result in some harm to thepatient, occur in this health setting though. There are still many knowledge gaps regarding this issue and difficulty to measure the types ofincidents that occurred. The studies are still incipient in this field, despite the greater visibility ofthe subject in Brazil, after the initiative to create the National PatientSafety Program (PNSP). (3,4)
The results show that the majority of nurses in our study (51.4%) have notified some type of event in the last year. Of these 29.7% notified 1 to 2 events and 21.7% notified 3 or more events. The remaining 48.6%, almost half ofthe study population, did not make any notifications, result that, supported by theoretical support that we had access reveals concern. Other studies carried out in this context present results lower than ours. In the study carried out by Garcia (2015) the majority of nurses (95.6%) did not make any event notification, Costa (2014), inferred that 77.9% ofthe respondents did not report any event/occurrence. Also the study of de Eiras et al. (2011), shows that the majority of participants, (73%), did not report any events/occurrences. These results demonstrate that underreporting is a reality in many hospitals representing a priority area of intervention, in a patient-centered health system notification ofincidents is essential, corroborating the notion that the real dimension of this problem is unknown in Portugal, as well as the consequences that come from the culture of underreporting (Costa 2014). Antunes (2015) states that 62.0% of adverse incidents/events are not reported, although our study presented a notification rate of 51.4% there is a large margin for improvement.
consequence for patients and their families. For the staff involved too, incidents can be distressing, while members of their clinical teams can become demoralised and disaffected. Safetyincidents also incur costs through litigation and extra treatment. Patientsafety is nowadays a serious problem of public health, with several implications in different clinical areas and level of care. It is crucial to establish priorities, hierarchy’s interventions and engaged all stakeholders who are involved around this big issue. In other word, it is important to define a strategy that could reflect a global framework, which allow us to integrate, articulate and be actors action-oriented, with the final aim of reducing the possibilities to harm patients. Consequently, these could contribute for a health care delivery of excellence and based on the best evidence.
Falls, transfusion reactions, and care-related infections are investigated by the Fall Prevention Group, Transfusion Committee, and CCIH, respectively. The other incidents are investigated according to degree of damage: mod- erate and serious events are NSP’s responsibility and the risks circumstances, almost error, incidents without dam- age, or light damage are managed by the area leaders. A standard instrument is used and the research tool used is the Ishikawa Diagram (15) . In compliance with the ministerial
Martinez et al. (2011), (52) reveal that most cardiac surgery errors occur in the operating room. This is not surprising considering the complexity of procedures and surgical team dynamics in the operating room. The researchers also find that the use of new technology, team member personalities, communication failures, and high workload and competing tasks, all affected team performance and jeopardized patientsafety. Furthermore, they suggest that surgical staff may perceive that deviating from safe practices is admissible because there are safety nets to catch errors. Although the majority of errors in this analysis did not result in reported harm, these incidents provide important information. It has been shown that an increase in the number of minor events (i.e. anything that disrupts surgical flow, but in isolation is not expected to impact on thesafetyofthepatient) decreases the ability ofthe cardiac surgery team to compensate for a future major event in the same case. Thus, no-harm incidents may reflect latent failures in the system that, under different circumstances, could result in patient harm or reduce the ability of a system to compensate for major errors.
Nas unidades de saúde é possível realizar estudos que visam apontar os principais aspectos e questões relacionadas com a cultura de segurança, por exemplo, com a aplicação do instrumento Medical Office Survey on PatientSafety Culture (MOSPSC) que foi traduzido e adaptado para se tornar a Pesquisa sobre Cultura de Segurança do Paciente para Atenção Primária. O questionário permite identificar a cultura de segurança do paciente na Atenção Primária à Saúde, observando se esta é favorável ou não. Um ambiente favorável e seguro ao paciente é identificado quando as respostas positivas superam 50% de todo o questionário; além disso, a ferramenta permite a identificação de pontos que precisam ser melhorados, funcionando como um importante indicador de necessidade de mudanças (RAIMONDI et al,. 2019).
Introduction: Cervical cancer is a serious public health problem because of its high incidence and mortality in developing countries and is, therefore, a priority in global health. Organized screening programs can reduce the incidence and mortality of cervical cancer due to the early detection of precancerous lesions. Objective: To evaluate the incomplete information from cervical cytology test requisitions ofthe National Cancer Control Programme ofthe Brazilian Ministry of Health (MoH), verifying the percentage of non-completion in a municipality in western Paraná, Brazil. Methods: A retrospective and quantitative study was carried out, based on data from cervical cytology test requisitions, from women attended by the Unified Health System [Sistema Único de Saúde (SUS)] in a municipality in western Paraná from May 2014 to May 2015. Results: The failure to provide the information occurred in 9,010 (40.9%) requisitions. The information not provided is mandatory for the health team responsible for collecting this exam in accordance with MoH guidelines. Conclusion: There is a need for professional training about filling in the information on requisitions, because they collaborate with the increase ofthe sensitivity and specificity ofthe cytology test, thus allowing more reliable results that aid in patientsafety.
Comparing serum cytokines there was a significant increase of IFNg in responders versus non-responders. At first glance this seems contradictory since INFg has been described as a proinflammatory Th1 cytokine, inducing CNS inflammation in animal models [13, 14] and leading to an MS exacerbation in a clinical trial . On the other hand there are reports that mice deficient for the IFNg receptor are more susceptible for and develop a more severe EAE  and that EAE disease severity is inhibited by induction of IFNg early during disease course . Considering the limited sample size it remains to be shown if this increase of IFNg in responders can be reproduced in a larger prospective cohort of patients. Since this result did not remain significant after correcting for multiple testing it has to be interpreted with caution.
We used confirmatory factor analysis (CFA) for ordinal data to compare the Portuguese sample factor structure to the factor structure reported for the original HSOPSC. CFA for ordinal data will use diagonally weighted least squares (DWLS) to estimate the model parameters, but it will use the full weight matrix to compute robust standard errors and a mean- and variance-adjusted test statistic. We used the goodness-of-fit index (GFI), which accounts for the proportion of observed covariance between the manifest variables (items), explained by the fitted model (a concept similar to the coefficient of determination in linear regression). Generally, GFI values between 0.9 and 0.95 indicate good fit, and GFI values above 0.95 indicate a very good fit. Bentler’s comparative fit index (CFI) was used to correct the underestimation that can occur when samples are small. CFI is independent from the sample size. Values between 0.9 and 0.95 indicate good fit, and values equal to or above 0.95 indicate a very good fit. The Tucker-Lewis index (TLI) varies between 0 and 1; values close to 1 indicate a good fit. Parsimony GPI (PGFI) is obtained to compensate for the “artificial” improvement in the model, which is achieved simply by adding more parameters, i.e., a more complex model may have better fit than a simpler model (parsimonious). Values between 0.6 and 0.8 indicate a reasonable fit and values above 0.8 a good fit. The index root mean square error of approximation (RMSEA) was used to adjust the model simply by adding more parame- ters. Empirical studies suggest that the model fit is considered good for values ranging between 0.05 and 0.08 and very good for values less than 0.05. The lavaan library from R was used .
Sensitivity analysis using the D-Sight Software assures us that, in the evaluation ofthe criteria by the decision makers, the input values ofthe model are in line with the final result within the stability range (Figure 1), there being no incoherence of preferences type A<C in the application of logic A>B>C (strict preference). As for the index values of each dimen- sion, there was no direct participation ofthe decision makers, since they were calculated by summing the criteria related to each dimension, weighted by the respective Professional Category Weights (wCP), according to the relationships proposed in Figure 2 and summarized in the following formula:
Objective: to identify the scientific evidence on PatientSafety (PS) in intravenous therapy in the Intensive Care Unit (ICU). Method: integrative review conducted in the Theses Database Higher Education Personnel Improvement Coordination (CAPES) and the WHO Collaborating Centre for Quality of Care and PatientSafety (PROQUALIS) portal. Results: there were 21 productions, seven studies cited to intravenous therapy. The studies, categorized into levels of evidence 1, 2 and 7, include structural, materials and professional performance ofthe steps of prescription, dispensing, preparation and administration of medications aspects. The productions have low levels of evidence, and therefore do not exhibit strong degree of recommendation. Conclusion: it is believed that the establishment and maintenance of PS in intravenous therapy in ICU greater investment is needed in research with higher levels of evidence and professional preparation to act as the recommended practices. Descriptors: Patientsafety, Intensive care, Administration intravenous.
to approach employees in person instead of via remote strate- gies, which are more prone to give rise to a less diverse sample population and a lower response rate. The institution surveyed here is a university hospital and its staff include a wide variety of professionals for the purposes of undergraduate education, residency and specialization. These data may suggest that high turnover exists, 33,34 and this may have been related to the low
This field test achieved its aims because ofthe enthusiastic participation of twelve universities/ schools that served as pilot sites to test the use ofthe WHO PatientSafety Curriculum Guide: Multi-professional Edition for teaching patientsafety. The twelve universities/schools are: Argentina: University of Del Salvador, School of Nursing, Faculty of Medicine, Buenos Aires; Egypt: Cairo University, Faculty of Oral and Dental Medicine, Cairo; Ethiopia: Gondar Univer- sity, College of Medicine and Health Sciences, Gondar; Greece: University of Athens, School of Dentistry, Athens; India: All India Institute of Medical Sciences, Center for Dental Education and Research, New Delhi; Jordan: Jordan University of Science and Technology, Faculty of Nursing, Irbid; Malaysia: United Nations University–International Institute for Global Health, Department of Nursing and Department of Community Health, the Faculty of Medicine and Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur; Mexico: National Autonomous University of Mexico, School of Dentistry, Mexico City; The Philippines: Univer- sity ofthe Philippines, College of Nursing and College of Medicine, Manila; Sir Lanka: Univer- sity of Peradeniya, Department of Nursing, Faculty of Allied Health Sciences, Peradeniya; UK: University ofthe West of Scotland, School of Health, Nursing & Midwifery, Paisley, Scotland; Zimbabwe: University of Zimbabwe, College of Health Science, Harare.
In the study entitled “Development ofthe German version ofthe Hospital Survey on PatientSafety Culture: Dimensionality and psychometric proper- ties” developed by (Pfeiffer & Manser 2010), was found that the global fit was not satisfactory. Three criteria indicated an adequate fit with the RMSEA=0.047, while GFI was 0.878, NFI was 0.859 and TLI was 0.901. These values showed that the fit is not sufficiently accurate to confirm the proposed factor structure. In the exploratory factor analysis, eight underlying factors explained 59.8% ofthe items variation. Overall, the scales showed satis- factory to good internal consistency. The Cronbach’s α ranged between 0.64 in the dimension “Communication openness” and 0.83 in the dimen- sion “Hospital management support for patientsafety”. This research was done with a sample of 3005 returned surveys, from which 2989 were valid, applied to the employees of a large University Hos- pital. This survey was developed to German speak- ing countries and the name was changed to PaSKI. About the participants on this research, 36.8% were registered nurses, 15% were managers and adminis- trators, 13.7% were physicians, 11.5% were medical and technical staff, 6.5% were nurse-assistants and the remaining were others. Response rate was 47%. In the study entitled “The psychometric properties ofthe 'Hospital Survey on PatientSafety Culture' in Dutch hospitals” developed by Smits et al. (2008), was found that the internal consistency measured by the Cronbach’s α ranged between 0.49 in the di- mension “Staffing” and 0.84 in the dimension “Fre- quency of event reporting”. Other dimensions that scored unacceptable reliability coefficients were “Organizational learning – continuous improve- ment” (α=0.57) and “Teamwork across hospital units” (α=0.59). The highest inter-dimension corre-
The perception of stress among nursing professionals ofthe institution under study had the lowest score, equal to 60%. A result that indicates the low capacity presented by the nursing staff to recognize how stress can compromise patientsafety. Authors point out that the hospital is an environment with numerous factors and situations that cause poor health and suffering, nursing is considered the profession with high occupational stress. 18
Objective: To formulate and to implement a virtual learning environment course in patientsafety, and to propose ways to estimate the impact ofthe course in patientsafety outcomes. Methods: The course was part of an accreditation process and involved all employees of a public hospital in Brazil. The whole hospital staff was enrolled in the course. The accreditation team defined the syllabus. The education guidelines were divided into 12 modules related to quality, patientsafety and required organizational practices. The assessment was performed at the end of each module through multiple-choice tests. The results were estimated according to occurrence of adverse events. Data were collected after the course, and employees’ attitude was surveyed. Results: More than 80% of participants reached up to 70% success on tests after the course; the event-reporting rate increased from 714 (16,264 patients) to 1,401 (10,180 patients). Conclusion: Virtual learning environment was a successful tool data. Data on course evaluation is consistent with increase in identification and reporting of adverse events. Although the report increment is not positive per si, it indicates changes in patientsafety culture.
This is a cross-sectional, quantitative study with a convenience sample of 235 nursing professionals, con- ducted in a private hospital and a public hospital in the state of São Paulo, Brazil. The private hospital (A) is a mid- sized institution with 120 nursing workers that attends patients from supplementary care and other users. The public hospital (B) is also mid-sized and mostly attends patients from the Unified Health System (SUS) of eight regional municipalities. It is a reference institution for women and children’s healthcare and has around 220 nursing workers.
The need for investments in order to qualify care in the ICU with regard to the prevention of corneal injury is not restricted to Brazil. A study carried out with 111 nurses in nine types of ICUs in two university hospitals in Turkey and Pales- tine showed that eye hygiene with normal saline is the most used by Palestinian nurses and gauze soaked in normal saline or sterile water, by Turkish nurses. Although it was shown that such nurses take preventive precautions for ocular complica- tions in critically ill patients, the study showed gaps and insufficiencies in the ophthalmological care of patients, and recommended continued training. 30