Experience of implementing the Patient Safety Center in primary health care

Abstract

Patient Safety refers to reducing the risks associated with health care to an acceptable minimum. Through ordinance No. 529/2013, the Ministry of Health launches the National Patient Safety Program to qualify care in all health establishments in Brazil and thus promote patient safety. Resolution No. 36/2013 makes the security nucleus in health institutions mandatory to organize and guarantee actions to control adverse events and improve care. Method: experience report to historically document the implementation of the patient safety nucleus in primary care, in a municipality with more than 653,000 inhabitants and 63 health units. Experiences of 4 members of the nucleus were collected through a semi-structured script on structuring, activities performed, notification flow and treatment of adverse events and action for improvements. Results: the nucleus was officially established in 2015 and is multidisciplinary, from the infection control team that already exists. The nucleus supports training on protocols and other training demands to network professionals, in the scope of patient safety and risk management. Its duties include receiving notifications and conducting analyzes and action plans in the face of adverse events, carrying out periodic technical visits and educational activities in line with the protocols and adjusted to each health unit. It has the challenge of disseminating the safety culture in the units, with a focus on leadership. Conclusion: the implementation of the primary care security nucleus is possible and requires efforts by multiple actors, involvement of leaders, continuous training of professionals, encouragement of notification and zeal for the culture of non-punitive accountability. This unprecedented experience shows feasibility and effective support for the implementation of the protocols and confirms the assertive contribution of the nucleus in improving security in the assistance provided in the municipality.