Patient safety culture in a university hospital

Original Article Rev. Latino-Am. Enfermagem 2018;26:e3014 DOI: 10.1590/1518-8345.2257.3014 www.eerp.usp.br/rlae Patient safety culture in a university hospital Taís Freire Galvão1 Marcélia Célia Couteiro Lopes2 Carmen Conceição Carrilho Oliva3 Maria Elizete de Almeida Araújo4 Marcus Tolentino Silva5 Objective: to assess patient safety culture in a university hospital. Method: cross-sectional study with data collection through the Hospital Survey on Patient Safety Culture applied in electronic device. A total of 381 employees were interviewed, corresponding to 46% of the sum of eligible professionals. Data were analyzed descriptively. the Cronbach’s alpha was used to calculate the frequency and reliability. Results: most were women (73%) from the nursing area (50%) and with direct contact with patients (82%). The composites related to “teamwork within units” (58%, α=0.68), “organizational learning – continuous improvement” (58%, α=0.63), “supervisor/ manager expectations and actions promoting patient safety” (56%, α=0.73) had higher positive responses. Nine composites had low positive responses, with emphasis on “nonpunitive response to error” (18%, α=0.40). Only the item “in this unit, people treat each other with respect” had positive response above 70%. The patient safety assessment in the work unit was positive for 36% of employees, however only 22% reported events in past year. Conclusion: the findings revealed weaknesses in the safety culture at the hospital, with emphasis on culpability. Descriptors: Patient Safety; Organizational Culture; Hospitals; Delivery of Health Care; Health Personnel; Surveys and Questionnaires. 1 PhD, Adjunct Professor, Faculdade de Ciências Farmacêuticas, Universidade Estadual de Campinas, Campinas, SP, Brazil. 2 MSc, Pharmacist, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas, Manaus, AM, Brazil. 3 MSc, Pharmacist, Unidade Básica de Saúde Leonor de Freitas, Secretaria Municipal de Saúde, Manaus, AM, Brazil. 4 PhD, Pharmacist, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas, Manaus, AM, Brazil. 5 PhD, Adjunct Professor, Faculdade de Medicina, Universidade Federal do Amazonas, Manaus, AM, Brazil. Adjunct Professor, Universidade de Sorocaba, Sorocaba, SP, Brazil. How to cite this article Galvão TF, Lopes MCC, Oliva CCC, Araújo MEA, Silva MT. Patient safety culture in a university hospital. Rev. LatinoAm. Enfermagem. 2018;26:e3014. [Access ___ __ ____]; Available in: ___________________ . DOI: http://dx.doi. org/10.1590/1518-8345.2257.3014. month day year URL 2 Rev. Latino-Am. Enfermagem 2018;26:e3014. teaching hospital of the Federal University of Amazonas, Introduction managed by the Brazilian Company of Hospital Services Patient safety culture corresponds to values and (Empresa Brasileira de Serviços Hospitalares) and behaviors of members in an institution and collectively contracted by the Brazilian Unified Health System. The represents the degree of institutional commitment with the safety of its processes (1). This construct reflects intangible aspects of health care, influenced exceedingly by the leadership, supervision and feedback to professionals(2). Caregivers recognize to be inserted research was conducted from June to September 2015. Healthcare and administrative employees (including public servants, temporary employees or professionals of the multi-professional and medical into an institution in which to follow the procedures is residency program) working at least for three months important. Therefore, they mark out their actions by in the institution were elected. Employees that were performing the good practices of the area and providing separated, on leave, or worked outside the main information for its continuous improvement . building of the hospital were ineligible. (3) Institutions with patient safety potentially provide Participants were selected by convenience sampling. safe care of better quality to their patients. The best A schedule to visit all sectors in the three shifts and scores on dimensions regarding safety culture were weekends was prepared in the period of the research. A related to the lower incidence of surgical site infection total of 381 employees were interviewed, corresponding in hospital(4), reduction of injuries, critical adverse events and risk-adjusted mortality(5). In risk-adjusted morbidity analyses of the patients and characteristics of the hospital, however, the positive responses of safety culture were not related to mortality in patients with acute myocardial infarction(6), nor was affected after reduction of catheter-associated infections(7). The safety culture in healthcare environments is to 46% of the sum of eligible professionals. Before the beginning of the interviews, the hospital commissioner communicated the managers about the research and encouraged the participation of employees. To inform the objectives and convoke the participants, advertisements about the research were posted in the murals of the hospital. typically assessed by quantitative surveys based on The primary outcome was defined as the proportion individual items and combination of composites(1). In of positive responses in each composite of the Hospital Brazil, the National Patient Safety Program (Programa Survey on Patient Safety Culture (HSOPS). Demographic Nacional de Segurança do Paciente), established by (sex, age, educational level) and professional (work unit, the Ordinance 529/2013 of the Brazilian Ministry of staff position or function, how long he/she has been Health, has safety culture as implementation strategy. working in the hospital, weekly workload) variables were The evaluation of patient safety culture is the first step to find the aspects that require improvement in this process. In the Brazilian context, some initiatives to measure and evaluate safety culture in institutions have been registered(8-11), revealing weaknesses in different aspects. There still prevails the perception that failures collected for sample characterization. The HSOPS was translated, transculturally adapted and validated for use in the Brazilian context (13-14). The survey consisted of 42 questions distributed in 12 composites and three levels: (i) work unit (supervisor/ manager expectations and actions promoting in patient safety point to individual responsibilities and, patient safety; organizational learning – continuous consequently, punitive actions for the professional. This improvement; staffing; communication openness; posture prevents the establishment of the improvements feedback and communication about error; nonpunitive required. In the Northern Region of Brazil, which is response to error; and teamwork within units, (ii) historically less developed and with lower supply of hospital organization (management support for patient health professionals and services(12), this scenario is safety; teamwork across units; and handoffs and possibly more prevalent. This region of the country transitions) and (iii) results (patient safety grade; and lacks investigations on safety culture. The objective of this research was to assess the patient safety culture in a university hospital from Manaus, Amazonas. Methods frequency of events reported). The two questions of result (perception of patient safety and number of safety events reported in the last 12 months) were evaluated separately, without constituting composites. The responses of HSOPS were codified by the Likert Cross-sectional study developed in the Getulio scale of five points (agreement: strongly disagree, Vargas University Hospital, in Manaus, Amazonas. It is a disagree, neither, agree, strongly agree; frequency: www.eerp.usp.br/rlae Galvão TF, Lopes MCC, Oliva CCC, Araújo MEA, Silva MT. never, rarely, sometimes, most of the time, always). of professionals available in the study period and in all The results were evaluated based on the performance shifts of work was invited. of each item and composite. The items and composites The variables collected were statistically described. with 75% of positive responses were considered strong The questions of the HSOPS were grouped in the 12 and the ones less than 50% were considered weak(15). composites, and the ones with negative responses were The Portuguese version of the HSOPS was loaded reversed. The proportion of positive responses to each in electronic questionnaire in the KoboToolbox software item was calculated: the numerator was the total of and made available in tablets of the Samsung Tab-3 positive responses and the denominator was the total SM-T110. The questions were sequentially disposed of respondents. and configured with mandatory responses in each The reliability of the composites was calculated question to avoid data loss. The research team tested using the Cronbach’s alpha. Values ≥0.6 were considered the electronic survey questionnaire to verify the understanding of questions and adequacy of the survey to the interface adopted. In these rounds, the need to improve the writing of three questions of the HSOPS was observed, as stated of good reliability. The Stata 14.2 software was used for all calculations. Missing data were excluded from the analysis, without imputation. The project was approved by the Research Ethics Committee of the Universidade Federal do Amazonas, through the opinion 1,082,410 from 05/27/2015, in a previous analysis(16). The term “event reports” in certificate of presentation for ethical consideration questions C1 and G1 was replaced by “notifications”, (CAAE) 44286115.0.0000.5020 of the Plataforma Brasil. term consolidated in Brazilian health services. Question A5 was written as “sometimes, the best patient care is not provided due to the excessive workload” instead of “staff (regardless of employment relationship) in this unit work longer hours than is best for patient care”(16). Undergraduate students, pharmacy and medicine Results A total of 401 employees were invited to participate in the study and 381 accepted (response rate: 95%), which represented 46% of eligible employees (Figure 1). residents and employees from the sector of Health and Patient Safety Surveillance of Brazil were trained to conduct the interviews, which occurred in the sector and 1,209 employees working hours of the employees. 380 ineligible (on vacation, on leave or on transfer) After the participant signed the informed consent form, the interviewer explained how to answer the questionnaire in the tablet. The device was delivered and the interviewer stood available for answering potential questions. 829 eligible 401 invited to participate (48%) We aimed at minimizing the risk of selection bias by previous communicating the occurrence of the survey and sending motivational messages to encourage the participation of employees in the research. Refusals were registered to the assessment of the response rate of the survey. The choice of using questionnaires in tablets, 20 refusals (11 men and 9 women) 381 participants (46%) Figure 1. Selection process of the survey participants at the university hospital, Manaus, AM, 2015 which were filled out by the professional, was due to the goal of ensuring the confidentiality and avoiding Sociodemographic characteristics shown in Table 1 embarrassment of the participant in informing data of demonstrate that most of the respondents were women personal (feelings, expectations) and professional nature with mean age of 39±11 years. More than 80% had (insecure behaviors, conceptions on the institution and direct contact with patients and 50% had graduate management). Such cautions aimed at minimizing risk studies. Half of respondents was from the nursing body, of measurement bias. among technicians (35%) and nurses (15%) and have Because it is a descriptive research, the calculation of sample size was dismissed. The maximum number www.eerp.usp.br/rlae been worked there for a year (50%). Most had weekly workload between 20 and 39 hours (66%). 3 4 Rev. Latino-Am. Enfermagem 2018;26:e3014. Table 1. Characteristics of professionals interviewed Table 2. Proportion of positive responses and reliability at the university hospital, Manaus, AM, Brazil, 2015 using the Cronbach’s alpha (α) of each composite of the (n=381). Hospital Survey on Patient Safety Culture instrument Characteristic n (%) Female 278 (73) Age (mean±SD*) at the university hospital, Manaus, AM, Brazil, 2015 (n=381) Patient safety culture composite 38.6±11.0 Direct contact with patients 310 (81) Educational level α % Teamwork within units 58 0.68 Organizational learning – continuous improvement 58 0.63 56 0.73 High school† 107 (28) Supervisor/manager expectations and actions promoting patient safety Complete higher education 83 (22) Frequency of events reported 44 0.88 191 (50) Communication openness 41 0.64 Feedback and communication about error 38 0.75 37 0.66 Graduate studies Work unit Diverse 120 (31) Teamwork across units Surgical 85 (22) Handoffs and transitions 36 0.71 Management support for patient safety 35 0.78 Overall perception of patient safety 33 0.48 Staffing 33 0.42 Nonpunitive response to error 18 0.40 Clinic 67 (18) Diagnostic and therapeutic support‡ 65 (17) Intensive care 45 (12) Position or function in the hospital Nurse technician 132 (35) Nurse 58 (15) Another higher-level professional§ 58 (16) Physician 40 (10) Administrative 37 Technician|| 28 (7) Other 28 (7) Time working in the hospital (years)¶ The majority of items (31/42) had negative responses, and only the item A4 – “in this unit, people treat each other with respect” had more than 70% of positive responses (data not presented). Patient safety culture assessment in the work unit was positive for 36% of employees, according Table 3. Of these, the majority filled out no reports in the last 12 months (78%) and 2% filled out six reports or more. <1 137 (50) 1 to 10 112 (40) Table 3. Quality of patient safety in the unit and >11 127 (46) number of reports filled out in the last 12 months at the Weekly workload (hours) university hospital, Manaus, AM, Brazil, 2015 (n=376) less than 20 to 39 252 (66) 40 to 59 82 (22) > 60 47 (12) * standard deviation † includes 4 people with some high school ‡ rehabilitation, pharmacy, laboratory, radiology § physical therapist, nutritionist, pharmacist, biologist, social worker, psychologist, dentist || electrocardiography, laboratory, radiology, pharmacy ¶ 5 interviews missing this information proportion of positive responses were: teamwork within units (58%); organizational learning – continuous (58%); and N* (%) Excellent 22 (6) Very good 113 (30) Acceptable 192 (51) Poor 35 (9) Failing 14 (4) Number of event reports filled out in the last 12 months According to Table 2, the composites with greater improvement Variables Patient safety grade supervisor/manager No reports 294 (53) 1 to 2 53 (30) 3 to 5 22 (13) 6 or more 7 (4) * 5 interviews missing these variables expectations and actions promoting patient safety (56%). The others had less positive responses than Discussion 50%, and the composite “nonpunitive response to error” had the lowest rate (18%). The safety culture measured by the HSOPS showed The HSOPS had good reliability using the Cronbach’s weaknesses for the university hospital assessed. Only alpha (0.63−0.88), except for the composites of “overall three composites had positive responses above 50% perceptions of patient safety” (0.48), “staffing” (0.42) and none represented strengths (above 75%) in patient and “nonpunitive response to error” (0.40). safety culture. www.eerp.usp.br/rlae 5 Galvão TF, Lopes MCC, Oliva CCC, Araújo MEA, Silva MT. The instrument used had good reliability using the Cronbach’s alpha in two thirds of the composites. The strategy used to improve the understanding of some questions, as pointed by other researchers to error and supervisor/manager expectations and actions promoting patient safety, respectively)(8). Composites with better scores (organizational , learning – continuous improvement, teamwork within increased the reliability of the composites in relation to units and supervisor/manager expectations and actions validation(14). Another strategy would be the exclusion of promoting patient safety) were similar to the strengths low-performance questions observed in Saudi studies, but had modest positive (14) (16) , however the instrument would have less items than the HSOPS originally responses given other international studies(20,24-26). developed. A new version of the HSOPS was validated Most respondents reported no adverse events in the for the Brazilian context and developed in an interface of past year. If on the one hand there is recognition of error electronic application(17). The reliability of the instrument and the importance of communicating it, on the other hand was high (α=0.92), possibly avoiding the interpretation there is omission of it due to absence of communication(27). limitations of the version applied in this investigation . Previous studies had better results, with proportions of The composite with lowest proportion of positive reports between 22% to 53%(8,20-22,25). National estimates responses was the “nonpunitive response to errors”, indicate incidence of 5% of preventable adverse events which also had the lowest reliability. In addition during hospitalization(28). The systemic approach to error, (14) to this composite having a problematic aspect in institutions – the culpability culture –, it consisted of only negative questions, which required higher attention on interpretation and had less reliability in questionnaires(18). Analyses of psychometric properties of HSOPS point to possible weaknesses in measuring the patient safety culture(19). Composites with lower scores may reflect the writing of items and not necessarily the weaknesses in safety culture. as opposed to the culpability, is strategic to improve the healthcare processes, covering the human nature involved in the processes and the complexity of health activities(29). Unsafe procedures must be redesigned and monitored to avoid the occurrence of the error, which results from latent and active faults in the system and not from an isolated individual. Our findings result from the interviews with almost half of the total of eligible employees based on a valid The result found in the composite “nonpunitive response to error” resembles studies carried out in intensive care in Brazil, in which this composite had the lowest proportion between composites of patient safety culture (14% to 29%)(8,20-21). These lower positive responses were also observed in a systematic review with meta-analysis, in which seven of 11 studies included showed the lowest frequencies in the composite(22). instrument to measure the patient safety culture in a university hospital. The findings possibly resemble other contexts of the Brazilian Unified Health System, which suffer with the underfunding. We highlight that this research establishes the first effort in measuring the patient safety culture in the Northern Region of Brazil. Conclusion Another factor that limits the results is the selection process by convenience of respondents, which decreases The patient safety culture in the university hospital the representativeness of the hospital staff. The HSOPS was evaluated as still fragile. To invest in systematic ignores the recommendations on the sampling process – approach to errors, professional team and management thus, the questionnaire can be forwarded by e-mail is a priority to strengthen the patient safety at hospital. and only the respondents are analyzed(15). We know The implementation and assessment of improvements that recruitment of participants influences the results, in care, associated with the systematic measurement of especially in internet surveys(23). On the other hand, the safety culture are strategies to increase the patient almost half of all employees eligible to the survey were safety in hospital. interviewed and included in this study. Our findings proportionally had more positive Acknowledgments responses than a study carried out in Southern Region of Brazil in 2016 with 59 participants of the health team We thank the academics, residents and of an intensive care unit, whose variation was from 14% employees of Hospital Universitário Getúlio Vargas, to 47% of positive responses . On the other hand, Universidade Federal do Amazonas for their assistance we had less positive responses than study carried out in data collection: Bárbara Pimentel, Eliana Brasil in 2014 in a teaching hospital of São Paulo with 88 Alves, Henderson Hirata, Marcus Vinícius Andrade, health professionals, in which the safety culture reached Mércia Christie Silva, Rayssa Cantisani, Renato Morais e proportions between 29% to 75% (nonpunitive response Stephan Azevedo. www.eerp.usp.br/rlae (21) 6 Rev. Latino-Am. Enfermagem 2018;26:e3014. References hospitals in the Brazilian Federal District. BMC Res Notes. 2016;9:276. doi: 10.1186/s13104-016-2078-3. 1. Halligan M, Zecevic A. Safety culture in healthcare: a 12. Sousa A, Dal Poz MR, Carvalho CL. Monitoring review of concepts, dimensions, measures and progress. Inequalities in the Health Workforce: The Case Study of BMJ Qual Safety. 2011;20(4):338-43. doi: 10.1136/ Brazil 1991–2005. PLoS One. 2012;7(3):e33399. doi: bmjqs.2010.040964. 10.1371/journal.pone.0033399. 2. Sexton JB, Adair KC, Leonard MW, Frankel TC, 13. Reis CT, Laguardia J, Martins M. [Translation and Proulx J, Watson SR, et al. Providing feedback following cross-cultural adaptation of the Brazilian version of Leadership WalkRounds is associated with better patient the Hospital Survey on Patient Safety Culture: initial safety culture, higher employee engagement and stage]. Cad Saúde Pública. 2012;28(11):2199-210. doi: lower burnout. BMJ Qual Safety. 2017. doi: 10.1136/ 10.1590/s0102-311x2012001100019. bmjqs-2016-006399. 14. Reis CT, Laguardia J, Vasconcelos AG, Martins M. 3. Lee SH, Phan PH, Dorman T, Weaver SJ, Pronovost Reliability and validity of the Brazilian version of the PJ. Handoffs, safety culture, and practices: evidence Hospital Survey on Patient Safety Culture (HSOPSC): a from the hospital survey on patient safety culture. BMC pilot study. Cad Saúde Pública. 2016;32(11):e00115614. Health Serv Res. 2016;16:254. doi: 10.1186/s12913- doi: 10.1590/0102-311x00115614. 016-1502-7. 15. Sorra JS, Dyer N. Multilevel psychometric properties 4. Fan CJ, Pawlik TM, Daniels T, Vernon N, Banks K, Westby of the AHRQ hospital survey on patient safety culture. P, et al. Association of Safety Culture with Surgical Site BMC Health Serv Res. 2010;10:199. doi: 10.1186/1472- Infection Outcomes. J Am Coll Surg. 2016;222(2):1228. doi: 10.1016/j.jamcollsurg.2015.11.008. 5. Berry JC, Davis JT, Bartman T, Hafer CC, Lieb LM, Khan N, et al. Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital Mortality Across a Hospital System. J Patient Safety. 2016. doi: 10.1097/pts.0000000000000251. 6. Shahian DM, Liu X, Rossi LP, Mort EA, Normand ST. Safety Culture and Mortality after Acute Myocardial Infarction: A Study of Medicare Beneficiaries at 171 Hospitals. Health Serv Res. 2017. doi: 10.1111/14756773.12725. 7. Meddings J, Reichert H, Greene MT, Safdar N, Krein SL, Olmsted RN, et al. Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives. BMJ Qual Safety. 2017;26(3):226-35. doi: 10.1136/bmjqs-2015-005012. 8. Santiago TH, Turrini RN. Organizational culture and climate for patient safety in Intensive Care Units. Rev Esc 6963-10-199. 16. Gama ZAdS, Batista AM, Silva IGd, Souza RMd, Freitas MRd. [Cross-cultural adaptation of the Brazilian version of the Hospital Survey on Patient Safety Culture: opportunities for improvement]. Cad Saúde Pública. 2013;29(7):1473-7. doi: 10.1590/S0102311X2013000700021. 17. Andrade LEL, Melo LOM, Silva IGD, Souza RM, Lima ALB, Freitas MR, et al. Adaptation and validation of the Hospital Survey on Patient Safety Culture in an electronic Brazilian version. Epidemiol Serv Saúde. 2017;26(3):455-68. doi: 10.5123/s167949742017000300004. 18. Schriesheim CA, Eisenbach RJ, Hill KD. The Effect of Negation and Polar Opposite Item Reversals on Questionnaire Reliability and Validity: An Experimental Investigation. Educ Psychol Meas. 1991;51(1):67-78. doi: 10.1177/0013164491511005. 19. Blegen MA, Gearhart S, O’Brien R, Sehgal NL, Alldredge BK. AHRQ’s hospital survey on patient safety culture: psychometric analyses. J Enferm USP. 2015;49 Spec No:123-30. doi: 10.1590/ Patient Safety. 2009;5(3):139-44. doi: 10.1097/ S0080-623420150000700018. PTS.0b013e3181b53f6e. 9. Toso GL, Golle L, Magnago TSBdS, Herr GEG, Loro 20. El-Jardali F, Sheikh F, Garcia NA, Jamal D, Abdo A. MM, Aozane F, et al. Patient safety culture in hospitals Patient safety culture in a large teaching hospital in within the nursing perspective. Rev Gaucha Enferm. Riyadh: baseline assessment, comparative analysis and 2016;37. doi: 10.1590/1983-1447.2016.04.58662. opportunities for improvement. BMC Health Serv Res. 10. Fermo VC, Radünz V, Rosa LMd, Marinho MM. 2014;14:122. doi: 10.1186/1472-6963-14-122. Professional attitudes toward patient safety culture in 21. Minuzzi AP, Salum NC, Locks MOH. Assessment of a bone marrow transplant unit. Rev Gaucha Enferm. patient safety culture in intensive care from the health 2016;37(1). doi: 10.1590/1983-1447.2016.01.55716. team’s perspective. Texto Contexto Enferm. 2016;25. 11. Santana HT, Rodrigues MC, do Socorro Nantua doi: 10.1590/0104-07072016001610015. Evangelista M. Surgical teams’ attitudes and opinions 22. Azami-Aghdash S, Ebadifard Azar F, Rezapour A, towards the safety of surgical procedures in public Azami A, Rasi V, Klvany K. Patient safety culture in www.eerp.usp.br/rlae 7 Galvão TF, Lopes MCC, Oliva CCC, Araújo MEA, Silva MT. hospitals of Iran: a systematic review and meta-analysis. Med J Islam Repub Iran. 2015;29:251. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC4715392/. 23. Bethlehem J. Selection Bias in Web Surveys. Int Stat Rev. 2010;78(2):161-88. doi: 10.1111/j.17515823.2010.00112.x. 24. Alonazi NA, Alonazi AA, Saeed E, Mohamed S. The perception of safety culture among nurses in a tertiary hospital in Central Saudi Arabia. Sudanese J Paediatrics. 2016;16(2):51. Available from: www.ncbi.nlm.nih.gov/ pmc/articles/PMC5237835/. 25. Davoodi R, Mohammadzadeh Shabestari M, Takbiri A, Soltanifar A, Sabouri G, Rahmani S, et al. Patient Safety Culture Based on Medical Staff Attitudes in Khorasan Razavi Hospitals, Northeastern Iran. Iran J Public Health. 2013;42(11):1292-8. Available from: www.ncbi.nlm.nih. gov/pmc/articles/PMC4499071/. 26. Nie Y, Mao X, Cui H, He S, Li J, Zhang M. Hospital survey on patient safety culture in China. BMC Health Serv Res. 2013;13:228. doi: 10.1186/1472-6963-13228. 27. De Cássia Pires Coli R, Dos Anjos MF, Pereira LL. The attitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics. Rev. Latino-Am. Enfermagem. 2010;18(3):324-30. doi: 10.1590/S0104-11692010000300005. 28. Mendes W, Pavão ALB, Martins M, Moura MdLdO, Travassos C. The feature of preventable adverse events in hospitals in the state of Rio de Janeiro, Brazil. Rev Assoc Med Bras. 2013;59:421-8. doi: 10.1016/j. ramb.2013.03.002. 29. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70. doi: 10.1136/ bmj.320.7237.768. Received: May 31th 2017 Accepted: Mar 20th 2018 Corresponding Author: Taís Freire Galvão Universidade Estadual de Campinas. Faculdade de Ciências Farmacêuticas Rua Candido Portinari, 200 Bairro: Barão Geraldo CEP: 13083-871, Campinas, SP, Brasil E-mail: tais.galvao@fcf.unicamp.br www.eerp.usp.br/rlae Copyright © 2018 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons (CC BY). This license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. This is the most accommodating of licenses offered. Recommended for maximum dissemination and use of licensed materials.