Incidentes com medicamentos e de comunicação na atenção primária à saúde: análise de causa raiz

Abstract

Objective: To analyze the root cause of medication and communication incidents involving PHC users, based on the literature, applying Ishikawa diagrams. Method: exploratory descriptive study carried out through a literature review to identify the main security incidents in PHC, with causes and consequences. The root cause method was applied using the Ishikawa diagram. Results:The two diagrams describe the failures in the work process that result in incidents with medications and communication, which present as a primary outcome the harm to the patient. Considerations relevant to Nursing: The present study supports new scientific research and assists nurses in the early recognition of risk factors that may compromise patient safety. Final considerations: The diagrams are tools to support research and training with a view to mitigating the human errors of incidents at this level of care.