Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem
Ano de defesa: | 2018 |
---|---|
Autor(a) principal: | |
Orientador(a): | |
Banca de defesa: | |
Tipo de documento: | Dissertação |
Tipo de acesso: | Acesso aberto |
Idioma: | por |
Instituição de defesa: |
Universidade Estadual de Feira de Santana
|
Programa de Pós-Graduação: |
Mestrado Acad?mico em Sa?de Coletiva
|
Departamento: |
DEPARTAMENTO DE SA?DE
|
País: |
Brasil
|
Palavras-chave em Português: | |
Palavras-chave em Inglês: | |
Área do conhecimento CNPq: | |
Link de acesso: | http://tede2.uefs.br:8080/handle/tede/847 |
Resumo: | Objective: To analyze the organizational factors contemplated in the Disciplinary Ethical Process (DEP) on the error in nursing work in light of the Swiss Cheese model by James Reason and the London Protocol. Methods: This master dissertation had two articles as a product. The first refers to a meta-synthesis made in the database of the BVS with the descriptors "erro and enfermagem", in the period from 2012 to 2017, in national and international literature, using thematic content analysis. The second article deals with a unique case study of a DEP of the Regional Council of Nursing of Bahia, with delineation of documentary research and qualitative approach. For the analysis of the organizational factors contained in the DEP, the London Protocol and the Theory of James Reason, 2000 to 2014, were used. Results: In the meta-synthesis 10 publications were analyzed, the following categories being identified and described, according to the theory of the Swiss Cheese model: Concept and Types of Error, Error Approach, Defense Barriers, Active Failures and Latent Conditions. Only two publications addressed the theory in depth. In the second article it was possible to identify the organizational factors contained in the DEP that contributed to the nursing error. Such as financial restrictions; organizational structure; policies, patterns, ambiguous protocols, unclear rules; and safety culture and priorities, according to the London Protocol and the James Reason Theory. Conclusions: Analyzing a Disciplinary Ethical Nursing Process in light of the Swiss Cheese Model by James Reason and the London Protocol made it possible to demonstrate the organizational factors that contributed to the error in nursing work. The studies presented in this paper on the subject reveal the dimension of the problem and the paramount need in the development of strategies for detection, research and intervention against the errors that occur in health services, with the aim of reducing and minimizing the risks for error. Understanding error as inherent to the human condition and facing the possibility of avoiding it allows us to recognize it as part of a system failure |
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Santos, Silvone Santa B?rbara da Silva35912421520http://lattes.cnpq.br/521951269870264381640927549http://lattes.cnpq.br/9794228194302853Andrade, Fl?via Pontes Guerra de Santana2019-08-20T19:05:52Z2018-05-30ANDRADE, Fl?via Pontes Guerra de Santana. Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalho de enfermagem. 2018. 103f. Disserta??o (Mestrado Acad?mico em Sa?de Coletiva) - Universidade Estadual de Feira de Santana, Feira de Santana, 2018.http://tede2.uefs.br:8080/handle/tede/847Objective: To analyze the organizational factors contemplated in the Disciplinary Ethical Process (DEP) on the error in nursing work in light of the Swiss Cheese model by James Reason and the London Protocol. Methods: This master dissertation had two articles as a product. The first refers to a meta-synthesis made in the database of the BVS with the descriptors "erro and enfermagem", in the period from 2012 to 2017, in national and international literature, using thematic content analysis. The second article deals with a unique case study of a DEP of the Regional Council of Nursing of Bahia, with delineation of documentary research and qualitative approach. For the analysis of the organizational factors contained in the DEP, the London Protocol and the Theory of James Reason, 2000 to 2014, were used. Results: In the meta-synthesis 10 publications were analyzed, the following categories being identified and described, according to the theory of the Swiss Cheese model: Concept and Types of Error, Error Approach, Defense Barriers, Active Failures and Latent Conditions. Only two publications addressed the theory in depth. In the second article it was possible to identify the organizational factors contained in the DEP that contributed to the nursing error. Such as financial restrictions; organizational structure; policies, patterns, ambiguous protocols, unclear rules; and safety culture and priorities, according to the London Protocol and the James Reason Theory. Conclusions: Analyzing a Disciplinary Ethical Nursing Process in light of the Swiss Cheese Model by James Reason and the London Protocol made it possible to demonstrate the organizational factors that contributed to the error in nursing work. The studies presented in this paper on the subject reveal the dimension of the problem and the paramount need in the development of strategies for detection, research and intervention against the errors that occur in health services, with the aim of reducing and minimizing the risks for error. Understanding error as inherent to the human condition and facing the possibility of avoiding it allows us to recognize it as part of a system failureObjetivo: Analisar os fatores organizacionais contidos no Processo ?tico Disciplinar (PED) sobre o erro no trabalho de Enfermagem, a luz do modelo Queijo Su??o de James Reason e o Protocolo de Londres. M?todos: Essa disserta??o de mestrado teve como produtos dois artigos. O primeiro trata-se de uma metass?ntese realizada na base de dados BVS com os descritores ?erro and enfermagem?, no per?odo 2012 a 2017, em literatura nacional e internacional, sendo utilizada a an?lise de conte?do tem?tica. O segundo artigo trata-se de um estudo de caso ?nico de um PED do Conselho Regional Enfermagem da Bahia, com delineamento de pesquisa documental e abordagem qualitativa. Para a an?lise dos fatores organizacionais contidos no PED utilizou-se do Protocolo de Londres e a Teoria de James Reason, 2000 a 2014. Resultados: Na metass?ntese foram analisadas 10 publica??es, sendo identificadas e descritas as seguintes categorias, atendendo a teoria do modelo do queijo su??o: Conceito e Tipos de erro, Abordagem do Erro, Barreiras de Defesas, Falhas ativas e Condi??es latentes. Somente duas publica??es abordaram a teoria com profundidade. No segundo artigo, foi possivel encontrar os fatores organizacionais contidos no PED que contribuiram para o erro de enfermagem. Sendo eles restri??es financeiras; estrutura organizacional; pol?ticas, padr?es, protoclos amb?guos, normas pouco clara; e cultura de seguran?a e prioridades, conforme o Protocolo de Londres e a teoria de James Reason. Conclus?es: Analisar um Processo ?tico Disciplinar de Enfermagem a luz do modelo Queijo Su??o de James Reason e do Protocolo de Londres permitiu elucidar os fatores organizacionais que contribu?ram para o erro no trabalho em enfermagem. Os estudos apresentados neste trabalho acerca desta tem?tica revelam a dimens?o de um problema e a necessidade primordial na elabora??o de estrat?gias para detec??o, investiga??o e interven??o diante dos erros que ocorrem nos servi?os de sa?de, no intuito de reduzir e minimizar os riscos para o erro. Entender o erro como inerente ? condi??o humana e encarar a sua inevitabilidade permite reconhec?-lo como parte de uma falha do sistemaSubmitted by Verena Pereira (verenagoncalves@uefs.br) on 2019-08-20T19:05:52Z No. of bitstreams: 1 DISSERTA??O FINAL - CD.pdf: 2588468 bytes, checksum: ae3f5e84be3808b74c75f8214d40249b (MD5)Made available in DSpace on 2019-08-20T19:05:52Z (GMT). No. of bitstreams: 1 DISSERTA??O FINAL - CD.pdf: 2588468 bytes, checksum: ae3f5e84be3808b74c75f8214d40249b (MD5) Previous issue date: 2018-05-30application/pdfporUniversidade Estadual de Feira de SantanaMestrado Acad?mico em Sa?de ColetivaUEFSBrasilDEPARTAMENTO DE SA?DEEnfermagemerro m?dicogest?o da seguran?aseguran?a do pacienteNursingmedical errorsecurity managementpatient safetyCIENCIAS DA SAUDE::SAUDE COLETIVASAUDE COLETIVA::SAUDE PUBLICAFatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermageminfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/masterThesis-21222253766072083266006006006001006395569471477890-61731671037544951993112649244584600979info:eu-repo/semantics/openAccessreponame:Biblioteca Digital de Teses e Dissertações da UEFSinstname:Universidade Estadual de Feira de Santana (UEFS)instacron:UEFSORIGINALDISSERTA??O FINAL - CD.pdfDISSERTA??O FINAL - CD.pdfapplication/pdf2588468http://tede2.uefs.br:8080/bitstream/tede/847/2/DISSERTA%C3%87%C3%83O+FINAL+-+CD.pdfae3f5e84be3808b74c75f8214d40249bMD52LICENSElicense.txtlicense.txttext/plain; charset=utf-82089http://tede2.uefs.br:8080/bitstream/tede/847/1/license.txt7b5ba3d2445355f386edab96125d42b7MD51tede/8472019-08-20 16:05:52.161oai:tede2.uefs.br:8080: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Biblioteca Digital de Teses e Dissertaçõeshttp://tede2.uefs.br:8080/PUBhttp://tede2.uefs.br:8080/oai/requestbcuefs@uefs.br|| bcref@uefs.br||bcuefs@uefs.bropendoar:2019-08-20T19:05:52Biblioteca Digital de Teses e Dissertações da UEFS - Universidade Estadual de Feira de Santana (UEFS)false |
dc.title.por.fl_str_mv |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
title |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
spellingShingle |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem Andrade, Fl?via Pontes Guerra de Santana Enfermagem erro m?dico gest?o da seguran?a seguran?a do paciente Nursing medical error security management patient safety CIENCIAS DA SAUDE::SAUDE COLETIVA SAUDE COLETIVA::SAUDE PUBLICA |
title_short |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
title_full |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
title_fullStr |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
title_full_unstemmed |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
title_sort |
Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalhode enfermagem |
author |
Andrade, Fl?via Pontes Guerra de Santana |
author_facet |
Andrade, Fl?via Pontes Guerra de Santana |
author_role |
author |
dc.contributor.advisor1.fl_str_mv |
Santos, Silvone Santa B?rbara da Silva |
dc.contributor.advisor1ID.fl_str_mv |
35912421520 |
dc.contributor.advisor1Lattes.fl_str_mv |
http://lattes.cnpq.br/5219512698702643 |
dc.contributor.authorID.fl_str_mv |
81640927549 |
dc.contributor.authorLattes.fl_str_mv |
http://lattes.cnpq.br/9794228194302853 |
dc.contributor.author.fl_str_mv |
Andrade, Fl?via Pontes Guerra de Santana |
contributor_str_mv |
Santos, Silvone Santa B?rbara da Silva |
dc.subject.por.fl_str_mv |
Enfermagem erro m?dico gest?o da seguran?a seguran?a do paciente |
topic |
Enfermagem erro m?dico gest?o da seguran?a seguran?a do paciente Nursing medical error security management patient safety CIENCIAS DA SAUDE::SAUDE COLETIVA SAUDE COLETIVA::SAUDE PUBLICA |
dc.subject.eng.fl_str_mv |
Nursing medical error security management patient safety |
dc.subject.cnpq.fl_str_mv |
CIENCIAS DA SAUDE::SAUDE COLETIVA SAUDE COLETIVA::SAUDE PUBLICA |
description |
Objective: To analyze the organizational factors contemplated in the Disciplinary Ethical Process (DEP) on the error in nursing work in light of the Swiss Cheese model by James Reason and the London Protocol. Methods: This master dissertation had two articles as a product. The first refers to a meta-synthesis made in the database of the BVS with the descriptors "erro and enfermagem", in the period from 2012 to 2017, in national and international literature, using thematic content analysis. The second article deals with a unique case study of a DEP of the Regional Council of Nursing of Bahia, with delineation of documentary research and qualitative approach. For the analysis of the organizational factors contained in the DEP, the London Protocol and the Theory of James Reason, 2000 to 2014, were used. Results: In the meta-synthesis 10 publications were analyzed, the following categories being identified and described, according to the theory of the Swiss Cheese model: Concept and Types of Error, Error Approach, Defense Barriers, Active Failures and Latent Conditions. Only two publications addressed the theory in depth. In the second article it was possible to identify the organizational factors contained in the DEP that contributed to the nursing error. Such as financial restrictions; organizational structure; policies, patterns, ambiguous protocols, unclear rules; and safety culture and priorities, according to the London Protocol and the James Reason Theory. Conclusions: Analyzing a Disciplinary Ethical Nursing Process in light of the Swiss Cheese Model by James Reason and the London Protocol made it possible to demonstrate the organizational factors that contributed to the error in nursing work. The studies presented in this paper on the subject reveal the dimension of the problem and the paramount need in the development of strategies for detection, research and intervention against the errors that occur in health services, with the aim of reducing and minimizing the risks for error. Understanding error as inherent to the human condition and facing the possibility of avoiding it allows us to recognize it as part of a system failure |
publishDate |
2018 |
dc.date.issued.fl_str_mv |
2018-05-30 |
dc.date.accessioned.fl_str_mv |
2019-08-20T19:05:52Z |
dc.type.status.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
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info:eu-repo/semantics/masterThesis |
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masterThesis |
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publishedVersion |
dc.identifier.citation.fl_str_mv |
ANDRADE, Fl?via Pontes Guerra de Santana. Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalho de enfermagem. 2018. 103f. Disserta??o (Mestrado Acad?mico em Sa?de Coletiva) - Universidade Estadual de Feira de Santana, Feira de Santana, 2018. |
dc.identifier.uri.fl_str_mv |
http://tede2.uefs.br:8080/handle/tede/847 |
identifier_str_mv |
ANDRADE, Fl?via Pontes Guerra de Santana. Fatores organizacionais no processo ?tico disciplinar sobre o erro no trabalho de enfermagem. 2018. 103f. Disserta??o (Mestrado Acad?mico em Sa?de Coletiva) - Universidade Estadual de Feira de Santana, Feira de Santana, 2018. |
url |
http://tede2.uefs.br:8080/handle/tede/847 |
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por |
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Universidade Estadual de Feira de Santana |
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