Preenchimento inadequado de dados cirúrgicos para segurança do paciente: opinião de profissionais da saúde

Abstract

Objective: to investigate variables related to inadequate completion of surgical data for patient safety in the hospi-tal setting in the opinion of health professionals. Methods: retrospective study in 180 medical records of surgical pa-tients in a public hospital and application of a structured questionnaire to caregivers responsible for filling out the surgical data of patients. Descriptive statistical analysis was performed. Results: the medical records showed incom-plete surgical records in the preoperative period (61%), intraoperative period (66%) and immediate postoperative period (87%). Professionals reported not knowing the pro-tocol for safe surgery (62%) and the institution's surgical safety form (68%), 87% were not trained to use the intra-operative checklist, 66% considered the number of staff in-adequate and 55% considered communication ineffective. Conclusion: in the opinion of health professionals, insuffi-cient professional knowledge, lack of training, inadequate staffing and ineffective communication may be related to inadequate completion of surgical data and patient safety.