Patient’ safety: challenges for nursing research and practice

Detalhes bibliográficos
Autor(a) principal: Silva, Ana Elisa Bauer de Camargo
Data de Publicação: 2010
Tipo de documento: Artigo
Idioma: por
eng
spa
Título da fonte: Revista Eletrônica de Enfermagem
Texto Completo: https://revistas.ufg.br/fen/article/view/11885
Resumo: doi: 10.5216/ree.v12i3.11885Nowadays the concerns with quality of care and patient' safety in health care institutions have been globally evidenced. The movement for patient' safety began in the last decade of the twentieth century after the U.S. Institute of Medicine report publication which presented results of several studies revealing the critical situation of health care in this country. The data showed that approximately 44.000 to 98.000 from 33.6 million of hospital patients has died due to adverse events(1). Since them the World Health Organization (WHO) has demonstrated its concern for patient' safety and has adopted this issue as high priority matter in the policy agenda for its countries members since the year of 2000. Last 2004, it was created the World Alliance for Safety Patients that aim to disseminate knowledge and found solutions. This alliance also has the goal of awareness and to gain political commitment for launching programs, generating alerts of systemic and technical aspects and conducting international campaigns that previously arrange the recommendations to ensure the safety of patients around the world(2). It was published in May 2007 the nine solutions for adverse events prevention in the health care(3). The current global challenges includes "Clean care is safety care" aiming to ensure better hands hygienization of the health care professionals, "Safe Surgery saves lives" aiming to improve better surgical treatment safety in all health care settings, and "Addressing the antimicrobial resistance" as a priority and focus to the World Health Day 2011(4). The main challenge of the experts in patient' safety that seek to reduce events in health care institutions has been the understanding, by the managers, that the cause of errors and adverse events is multifactorial and that health professionals are susceptible to commit adverse events when the technical and organizational processes are complex and poorly planned. The systems fail throughout the world and once the assistance is provided by humans there is the possibility of risk and harm promotion to patients, although what is really important now is that this reality is no longer ignored. The understanding that systems fail and allow the professionals failures spreads out reaching patients causing them adverse events allows the hospital to review its processes, to study and strengthen their defense lines. As a result f these global movements about this issue, scientific researches has been developed to identify and to understand the errors and adverse events, to adopt correctives actions and pro-actives, to analyze of the systemic fails and the cause factors and to establish strategies that ensure a safe practice, becoming better the quality of the health care and, consequently, offering a better patient' safety. A severe mistake found has been the lack of information about occurred adverse events and about its causal factors, impeding the knowledge, evaluation and the debate about the consequences of these events to the professionals, patients and familiar. This lack jeopardizes patient' safety because hinder the manager's actions to the achievement of planning and development of organizational strategies to the adoption of safe practices, minimization of the events and improving health care, setting risk for patient's security. Among the challenges for nursing when the subject are: the Patient' Safety Committee in health institutions composed by multidisciplinary team, seeking the development of a security culture inside or within these institutions and, the strengthening of a Nursing Network and Patient' Security (local, national and international) promoting rapid and effective communication of evidences, experiences and recommendations to ensure the patient' safety in the whole world. Another challenge, not least, is the scientific researches development that aims to minimize the known distance between what we know in theory and what we apply in the practice (know-do gap). Nursing needs to remodel the reasoning on existing researches about safety today in a solid path toward safer care assistance in the future. The researches on patient' safety should subsidize the decision-making and the management's intervention to modify the practice of care. The taken actions must generate results as reliable practices that make the difference in the safety of the patients, minimizing risks and changing the actual situation of the undesirable events.   REFERENCES 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/. 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html. 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29].  Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/.
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spelling Patient’ safety: challenges for nursing research and practiceSeguridad Del paciente: desafíos a la práctica y a la investigación en EnfermeríaSegurança do paciente: desafios para a prática e a investigação em Enfermagemdoi: 10.5216/ree.v12i3.11885Nowadays the concerns with quality of care and patient' safety in health care institutions have been globally evidenced. The movement for patient' safety began in the last decade of the twentieth century after the U.S. Institute of Medicine report publication which presented results of several studies revealing the critical situation of health care in this country. The data showed that approximately 44.000 to 98.000 from 33.6 million of hospital patients has died due to adverse events(1). Since them the World Health Organization (WHO) has demonstrated its concern for patient' safety and has adopted this issue as high priority matter in the policy agenda for its countries members since the year of 2000. Last 2004, it was created the World Alliance for Safety Patients that aim to disseminate knowledge and found solutions. This alliance also has the goal of awareness and to gain political commitment for launching programs, generating alerts of systemic and technical aspects and conducting international campaigns that previously arrange the recommendations to ensure the safety of patients around the world(2). It was published in May 2007 the nine solutions for adverse events prevention in the health care(3). The current global challenges includes "Clean care is safety care" aiming to ensure better hands hygienization of the health care professionals, "Safe Surgery saves lives" aiming to improve better surgical treatment safety in all health care settings, and "Addressing the antimicrobial resistance" as a priority and focus to the World Health Day 2011(4). The main challenge of the experts in patient' safety that seek to reduce events in health care institutions has been the understanding, by the managers, that the cause of errors and adverse events is multifactorial and that health professionals are susceptible to commit adverse events when the technical and organizational processes are complex and poorly planned. The systems fail throughout the world and once the assistance is provided by humans there is the possibility of risk and harm promotion to patients, although what is really important now is that this reality is no longer ignored. The understanding that systems fail and allow the professionals failures spreads out reaching patients causing them adverse events allows the hospital to review its processes, to study and strengthen their defense lines. As a result f these global movements about this issue, scientific researches has been developed to identify and to understand the errors and adverse events, to adopt correctives actions and pro-actives, to analyze of the systemic fails and the cause factors and to establish strategies that ensure a safe practice, becoming better the quality of the health care and, consequently, offering a better patient' safety. A severe mistake found has been the lack of information about occurred adverse events and about its causal factors, impeding the knowledge, evaluation and the debate about the consequences of these events to the professionals, patients and familiar. This lack jeopardizes patient' safety because hinder the manager's actions to the achievement of planning and development of organizational strategies to the adoption of safe practices, minimization of the events and improving health care, setting risk for patient's security. Among the challenges for nursing when the subject are: the Patient' Safety Committee in health institutions composed by multidisciplinary team, seeking the development of a security culture inside or within these institutions and, the strengthening of a Nursing Network and Patient' Security (local, national and international) promoting rapid and effective communication of evidences, experiences and recommendations to ensure the patient' safety in the whole world. Another challenge, not least, is the scientific researches development that aims to minimize the known distance between what we know in theory and what we apply in the practice (know-do gap). Nursing needs to remodel the reasoning on existing researches about safety today in a solid path toward safer care assistance in the future. The researches on patient' safety should subsidize the decision-making and the management's intervention to modify the practice of care. The taken actions must generate results as reliable practices that make the difference in the safety of the patients, minimizing risks and changing the actual situation of the undesirable events.   REFERENCES 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/. 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html. 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29].  Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/.doi: 10.5216/ree.v12i3.11885Actualmente la preocupación con la calidad de la atención y la seguridad del paciente en las instituciones de salud ha se evidenciado en nivel mundial. El movimiento en por de la seguridad del paciente se inició en la última década del siglo XX, después de la publicación del velatorio del Institute of Medicine - EEUU que presentó los resultados de varios estudios que revelan la crítica situación de salud en aquel país. Los datos mostraron que entre 44.000 a 98.000 entre 33,6 millones de pacientes ha muerto debido a eventos adversos(1). Desde entonces la Organización Mundial de la Salud (OMS) ha demostrado su preocupación por la seguridad del paciente y ha adoptado esto como un asunto de alta prioridad en la agenda política de sus países miembros desde el año de 2000. En 2004, se creó la Alianza Mundial para la Seguridad de los pacientes que tienen como objetivo difundir el conocimiento y las soluciones encontradas. Esta alianza también tiene como objetivo sensibilizar y lograr un compromiso político, lanzar programas, generando alertas en relación a los aspectos sistémicos y técnicos, y la realizar de campañas internacionales para garantizar la seguridad de pacientes en todo el mundo(2). En Mayo de 2007 fueron publicadas las nueve soluciones para la prevención de eventos adversos en la atención en salud(3). Los desafíos globales actuales incluyen "Cuidado limpio es cuidado seguro" objetivando garantir la mejoría de la higienización de las manos de los profesionales que trabajan en el cuidado, "Cirugías seguras que salvan vidas", objetivando mejorar la seguridad del tratamiento quirúrgico en todos los contextos de la atención en salud y "Hacer frente a resistencia a los antimicrobianos como una prioridad y el enfoque de Día Mundial de la Salud 2011"(4). El mayor desafío de los especialistas en seguridad del paciente, que buscan la reducción de los eventos en las instituciones de salud ha sido la asimilación, por parte de los administradores, de que la causa de los errores y eventos adversos es multifactorial y que los profesionales de salud están susceptibles a cometer eventos adversos cuando los procesos técnicos y organizacionales son complexos y mal planeados. Los sistemas fracasan en todo el mondo y desde que la asistencia sea prestada por seres humanos existe la posibilidad de promoción de riscos y danos a los pacientes, aunque o que sea de facto importante en esto momento es que esta realidad no sea mas ignorada. La comprensión de que los sistemas fallan y permiten que las fallas de los profesionales se extiendan alcanzando los pacientes y causando eventos adversos, permiten al hospital revisar sus procesos, estudiar y fortalecer sus barreras de defensa y las fallas latentes, que están presentes en los locales de trabajo y hacen el sistema frágiles y susceptible a errores. Como resultado de estos movimientos mundiales sobre este tema, las investigaciones científicas se han desarrollado para identificar y comprender los errores y eventos adversos, adoptar las acciones correctivas y pro-activas, analizar las fallas sistémicas y sus factores causales, y desenvolver estrategias que garantizan una practica segura, mejorando la calidad de la asistencia y, consecuentemente, ofreciendo mayor seguridad al paciente. Ha sido encontrado un grave problema que es la falta de información de los eventos adversos que ocurren y sus factores causales, impidiendo el conocimiento, la evaluación y la discusión de las consecuencias de estos eventos adversos para los profesionales, pacientes y familiares. Esta brecha perjudica la acción de los gestores a la realización del planeamiento y desenvolvimiento de estrategias organizacionales para la adopción de prácticas seguras, minimización de los eventos y mejoría de la asistencia, colocando en risco la seguridad de los pacientes. Entre los desafíos para la enfermería cuando el tema es: la creación de Comités de Seguridad del Paciente en las instituciones de salud constituida por equipo multidisciplinaria, con el fin de desarrollar una cultura de seguridad dentro de las instituciones y el fortalecimiento de la Red de Enfermería y Seguridad del Paciente (local, regional e internacional) promoviendo la comunicación rápida y efectiva de las evidencias, experiencias y recomendaciones destinadas a garantizar la seguridad de los pacientes en todo el mundo. Otro desafío, no menos importante, hasta el desarrollo de pesquisas científicas dirigidas a reducir al mínimo la distancia conocida entre lo que sabemos en la teoría y lo que se aplica en la practica (know-do gap). La enfermería tiene que transformar el discurso de la investigación en seguridad existente hoy en día en un camino sólido direccionado a una asistencia más segura en el futuro.  Las investigaciones en seguridad del paciente deben subsidiar las decisiones y las intervenciones de gestión, para alterar la práctica del cuidado. Las medidas adoptadas deben generar resultados como practicas confiables para hacer diferencia en la seguridad del paciente, reducir al mínimo los riesgos y cambiar la situación actual de los eventos no deseables.   REFERENCES 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/.  3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html. 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29].  Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/. doi: 10.5216/ree.v12i3.11885A preocupação com qualidade do cuidado e com a segurança do paciente nas instituições de saúde tem surgido em âmbito global. O movimento em prol da segurança do paciente teve seu início na última década do século XX, após a publicação do relatório do Institute of Medicine dos EUA que apresentou os resultados de vários estudos que revelaram a crítica situação de assistência à saúde daquele país. Dados apontaram que de 33,6 milhões de internações 44.000 a 98.000 pacientes, aproximadamente, morreram em consequência de eventos adversos(1). Desde então a Organização Mundial de Saúde (OMS) tem demonstrado sua preocupação com a segurança do paciente e adotou esta questão como tema de alta prioridade na agenda de políticas dos seus países membros a partir do ano 2000. Em 2004, criou a Aliança Mundial para Segurança do Paciente, visando a socialização dos conhecimentos e das soluções encontradas. Esta aliança tem também o objetivo de conscientizar e conquistar o compromisso político, lançando programas, gerando alertas sobre aspectos sistêmicos e técnicos e realizando campanhas internacionais que reúnem recomendações destinadas a garantir a segurança dos pacientes ao redor do mundo(2) . Em maio de 2007 foram publicadas as nove soluções para prevenção de evento adverso no cuidado à saúde(3). Os atuais desafios globais incluem "Cuidado Limpo é Cuidado Seguro" visando garantir a melhoria da higienização das mãos dos profissionais que atuam no cuidado, "Cirurgias Seguras Salvam Vidas", visando melhorar a segurança do tratamento cirúrgico em todos os contextos de cuidados de saúde e "Enfrentar a Resistência Antimicrobiana" como uma prioridade e o foco do Dia Mundial da Saúde de 2011(4). O maior desafio dos especialistas em segurança do paciente, que buscam a redução dos eventos nas instituições de saúde tem sido a assimilação, por parte dos dirigentes, de que a causa dos erros e eventos adversos é multifatorial e que os profissionais de saúde estão suscetíveis a cometer eventos adversos quando os processos técnicos e organizacionais são complexos e mal planejados. Os sistemas fracassam em todo o mundo e desde que a assistência seja prestada por seres humanos há a possibilidade de promoção de riscos e danos aos pacientes, embora o que seja de fato importante neste momento é que esta realidade não seja mais ignorada. A compreensão de que sistemas falham e permitem que as falhas dos profissionais se propaguem, atingindo os pacientes e causando eventos adversos, permite à organização hospitalar rever os seus processos, estudar e reforçar suas barreiras de defesa e as falhas latentes, que estão presentes nos locais de trabalho e que tornam o sistema frágil e suscetível a erros. Como resultado dos movimentos globais acerca dessa problemática, investigações científicas tem sido conduzidas para identificação e compreensão dos erros e eventos adversos, adoção de medidas corretivas e pró-ativas, análise das falhas sistêmicas e dos fatores causais, desenvolvimento de estratégias que garantam a prática segura melhorando a qualidade da assistência e, consequentemente, fornecendo maior segurança ao paciente. Um grave problema encontrado tem sido a falta de informações sobre os eventos adversos que ocorrem e sobre seus fatores causais, impedindo o conhecimento, avaliação e a discussão sobre as consequências destes eventos para os profissionais, usuários e familiares. Esta lacuna prejudica a ação dos gestores para realização do planejamento e desenvolvimento de estratégias organizacionais voltadas para a adoção de práticas seguras, minimização dos eventos e melhoria da assistência, colocando em risco a segurança dos pacientes. Entre os desafios para a enfermagem quando se trata do assunto estão: a criação de Comitês de Segurança do Paciente nas instituições de saúde constituída por equipe multidisciplinar, visando desenvolver uma cultura de segurança dentro das instituições e o fortalecimento da Rede de Enfermagem e Segurança do Paciente (Internacional, Nacional e Regional) promovendo a comunicação rápida e efetiva das evidências, experiências e recomendações destinadas a garantir a segurança dos pacientes ao redor do mundo. Outro desafio, não menos importante, está o desenvolvimento de pesquisas científicas que visem minimizar a reconhecida distância que existe entre o que se sabe em teoria e o que se aplica na prática (know-do gap). A enfermagem necessita transformar o discurso da pesquisa sobre segurança existente hoje, em um caminho sólido em direção a uma assistência mais segura no amanhã. As investigações sobre a segurança do paciente devem subsidiar as tomadas de decisão e as intervenções da gestão modificando a prática do cuidado.  As ações adotadas precisam gerar resultados como práticas confiáveis que façam a diferença na segurança dos pacientes, minimizando os riscos e alterando o quadro atual de eventos indesejáveis.   REFERÊNCIAS 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/. 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/. Faculdade de Enfermagem da UFG2010-09-30info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionArtigo Não Avaliado por Paresapplication/pdfapplication/pdfapplication/pdfhttps://revistas.ufg.br/fen/article/view/1188510.5216/ree.v12i3.11885Revista Eletrônica de Enfermagem; Vol. 12 No. 3 (2010); 422-4Revista Eletrônica de Enfermagem; v. 12 n. 3 (2010); 422-41518-1944reponame:Revista Eletrônica de Enfermageminstname:Universidade Federal de Goiás (UFG)instacron:UFGporengspahttps://revistas.ufg.br/fen/article/view/11885/7815https://revistas.ufg.br/fen/article/view/11885/7856https://revistas.ufg.br/fen/article/view/11885/7857Silva, Ana Elisa Bauer de Camargoinfo:eu-repo/semantics/openAccess2020-08-11T00:33:12Zoai:ojs.revistas.ufg.br:article/11885Revistahttps://revistas.ufg.br/fenPUBhttps://revistas.ufg.br/fen/oairee.fen@ufg.br1518-19441518-1944opendoar:2020-08-11T00:33:12Revista Eletrônica de Enfermagem - Universidade Federal de Goiás (UFG)false
dc.title.none.fl_str_mv Patient’ safety: challenges for nursing research and practice
Seguridad Del paciente: desafíos a la práctica y a la investigación en Enfermería
Segurança do paciente: desafios para a prática e a investigação em Enfermagem
title Patient’ safety: challenges for nursing research and practice
spellingShingle Patient’ safety: challenges for nursing research and practice
Silva, Ana Elisa Bauer de Camargo
title_short Patient’ safety: challenges for nursing research and practice
title_full Patient’ safety: challenges for nursing research and practice
title_fullStr Patient’ safety: challenges for nursing research and practice
title_full_unstemmed Patient’ safety: challenges for nursing research and practice
title_sort Patient’ safety: challenges for nursing research and practice
author Silva, Ana Elisa Bauer de Camargo
author_facet Silva, Ana Elisa Bauer de Camargo
author_role author
dc.contributor.author.fl_str_mv Silva, Ana Elisa Bauer de Camargo
description doi: 10.5216/ree.v12i3.11885Nowadays the concerns with quality of care and patient' safety in health care institutions have been globally evidenced. The movement for patient' safety began in the last decade of the twentieth century after the U.S. Institute of Medicine report publication which presented results of several studies revealing the critical situation of health care in this country. The data showed that approximately 44.000 to 98.000 from 33.6 million of hospital patients has died due to adverse events(1). Since them the World Health Organization (WHO) has demonstrated its concern for patient' safety and has adopted this issue as high priority matter in the policy agenda for its countries members since the year of 2000. Last 2004, it was created the World Alliance for Safety Patients that aim to disseminate knowledge and found solutions. This alliance also has the goal of awareness and to gain political commitment for launching programs, generating alerts of systemic and technical aspects and conducting international campaigns that previously arrange the recommendations to ensure the safety of patients around the world(2). It was published in May 2007 the nine solutions for adverse events prevention in the health care(3). The current global challenges includes "Clean care is safety care" aiming to ensure better hands hygienization of the health care professionals, "Safe Surgery saves lives" aiming to improve better surgical treatment safety in all health care settings, and "Addressing the antimicrobial resistance" as a priority and focus to the World Health Day 2011(4). The main challenge of the experts in patient' safety that seek to reduce events in health care institutions has been the understanding, by the managers, that the cause of errors and adverse events is multifactorial and that health professionals are susceptible to commit adverse events when the technical and organizational processes are complex and poorly planned. The systems fail throughout the world and once the assistance is provided by humans there is the possibility of risk and harm promotion to patients, although what is really important now is that this reality is no longer ignored. The understanding that systems fail and allow the professionals failures spreads out reaching patients causing them adverse events allows the hospital to review its processes, to study and strengthen their defense lines. As a result f these global movements about this issue, scientific researches has been developed to identify and to understand the errors and adverse events, to adopt correctives actions and pro-actives, to analyze of the systemic fails and the cause factors and to establish strategies that ensure a safe practice, becoming better the quality of the health care and, consequently, offering a better patient' safety. A severe mistake found has been the lack of information about occurred adverse events and about its causal factors, impeding the knowledge, evaluation and the debate about the consequences of these events to the professionals, patients and familiar. This lack jeopardizes patient' safety because hinder the manager's actions to the achievement of planning and development of organizational strategies to the adoption of safe practices, minimization of the events and improving health care, setting risk for patient's security. Among the challenges for nursing when the subject are: the Patient' Safety Committee in health institutions composed by multidisciplinary team, seeking the development of a security culture inside or within these institutions and, the strengthening of a Nursing Network and Patient' Security (local, national and international) promoting rapid and effective communication of evidences, experiences and recommendations to ensure the patient' safety in the whole world. Another challenge, not least, is the scientific researches development that aims to minimize the known distance between what we know in theory and what we apply in the practice (know-do gap). Nursing needs to remodel the reasoning on existing researches about safety today in a solid path toward safer care assistance in the future. The researches on patient' safety should subsidize the decision-making and the management's intervention to modify the practice of care. The taken actions must generate results as reliable practices that make the difference in the safety of the patients, minimizing risks and changing the actual situation of the undesirable events.   REFERENCES 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/. 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html. 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29].  Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/.
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dc.source.none.fl_str_mv Revista Eletrônica de Enfermagem; Vol. 12 No. 3 (2010); 422-4
Revista Eletrônica de Enfermagem; v. 12 n. 3 (2010); 422-4
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