The implementation of a patient safety center at a public hospital in São Bernardo do Campo, Brazil in May 2014 led to improved patient safety outcomes. In 2013, there were 170 reports of inadequate work processes with only 40% resolved, whereas in 2014 there were 581 reports with 91% resolved after the patient safety team was created. The team analyzed 3 sentinel events in 2014, which resulted in protocol reviews, staff training, and improved processes to prevent future issues. The creation of the patient safety team successfully encouraged more reporting of issues and improved resolution of problems to enhance patient safety.

1. Impact Analysis of Patient Safety Center Deployment in Brazilian Public Hospital
Jaqueline Tonelotto, Carla R. Y. Kobayashi, Taís A. Z. Vassi, Selma M. Costa,
João G. Negrão, Monica Carneiro, José Kleber Kobol Machado
MUNICIPAL HOSPITAL UNIVERSITY OF SÃO BERNARDO DO CAMPO
ABSTRACT
The implementation of patient safety center at the Municipal Hospital University of São
Bernardo do Campo, São Paulo, Brazil ocurred in May, 2014.This team is composed by a
doctor, a nurse and a administrative officer. The hospital performs assistance to women and
has a capacity of 140 beds distributed between maternity, neonatal ICU, pathological
nursery, adult ICU and gynecology.
Our objectve was to assess the impact of a team to advise on patient safety and increase
the culture of notifications of inadequate processes of work with direct impact on patient
care.
METHODS
Use of annual indicators of number of notifications and solving the years 2013,
preimplantation of security team, compared with 2014 with the implementation of patient
safety team.
RESULTS
In 2013 were performed 170 failure notifications work process with conclusion of 40% of
cases, 52% pending resolution and 8% of cases in progress. In 2014 compute 581
notifications in 91% completed, 8 % pending resolution and 1% of cases in progress. The
units that required further attention were the pharmacy/warehouse and the external
laboratory. In 2014 patient safety team analyzed 3 sentinel events with harm to the patient:
2 pressure ulcers and 1 medication error in the neonatal unit. After the analysis of these
cases the team held protocol review actions, staff training in pressure ulcer prevention and
the10 steps drug administration.
IN
PROGRESS
1%
NOTIFICATIONS,2014
n=581 PENDING
RESOLUTION
8%
CONCLUSION
91%
CONCLUSION
INPROGRESS
PENDING
RESOLUTION

2. Impact Analysis of Patient Safety Center Deployment in Brazilian Public Hospital
Jaqueline Tonelotto, Carla R. Y. Kobayashi, Taís A. Z. Vassi, Selma M. Costa,
João G. Negrão, Monica Carneiro, José Kleber Kobol Machado
MUNICIPAL HOSPITAL UNIVERSITY OF SÃO BERNARDO DO CAMPO
RESULTS CONTINUED CONCLUSIONS
REFERENCES
We can affirm that the creation of this team encouraged the notification of inadequacies and the team
acted in the adequacy of these complaints with improved work process, protocol review, intensification
of continuing education with a consequent increase in the safety of hospitalized patients.
• Annual indicators of Municipal Hospital University of São Bernardo do Campo
SERVIÇO MÉDICO
5% NEONATAL ICU 3%
NUTRITION 3%
LABORATORY
10%
HYGIENE AND
CLEANING
4%
NURSING
MANAGEMENT
5%
UNIT MANAGEMENT
5%
PHARMACY
28%BUILDING
ENGINEERING
4%
CLINICAL
ENGINEERING
3%
TRANSPORTATION
2%
LINEN
1%
RADIOLOGY
2%
CSE
1%
SURGERY CENTER
1%
WAREHOUSE
3%
ANOTHER UNITS
19%
DISTRIBUTION OF ERROR NOTIFICATIONS BY NOTIFIED UNITS, 2014