Abstract

A bibliometric review study, which aimed to map the scientific productions on patient safety in primary health care in the Brazilian context, carried out in the databases SCIELO, LILACS, BDENF, IBECS, from 2013 to 2022. The sample body integrated 23 articles. The year with the highest publication was 2019 (30.4%); the regions with the highest representation of studies were Southeast (43.5%) and South (34.8%); most of the studies were linked to public institutions, and the main authors had the training of nurses (74%). The most used methodological approach was quantitative (48%), the largest number of publications in journals with Qualis/Capes A1, and the main theme was patient safety culture (30.5%). The analysis of keywords identified the terms "health and quality" as central elements to patient safety. Three articles with homonymous titles were found that used the same collection instrument. It is concluded that the scientific production in this field was little expressive in the North, Northeast and Midwest regions. There was a predominance of authors from a single professional category and greater representativeness of an object of study, the safety culture. Low encouragement was observed to scientific production aimed at the involvement of the user in their own security.

Keywords:
Patient safety; Primary Health Care; Bibliometric studies

Introduction

The search for a guarantee of healthcare free from harm has brought together discussions on negative outcomes associated with health care and has boosted the formulation of public policies oriented to patient safety worldwide (Teixeira , 2021TEIXEIRA, T. B. C. et al. Avaliação da segurança do paciente na sala de vacinação. Texto Contexto Enferm., v. 30, e20200126, 2021. Disponível em: https://doi.org/10.1590/1980-265X-TCE-2020-0126. Acesso em: 12 nov. 2023.
https://doi.org/10.1590/1980-265X-TCE-20... ; Simplício , 2023SIMPLÍCIO, E. A. et al. Segurança do paciente assistido na atenção primária. Global Clinical Research Journal, [S. l.], v. 3, n. 1, p. e42, 2023. Disponível em: https://globalclinicalresearchj.com/index.php/globclinres/article/view/55. Acesso em: 11 nov. 2023.
https://globalclinicalresearchj.com/inde... ). In Brazil, the expansion of the scope of actions aimed at patient safety had a greater reach of political and regulatory commitment, with the implementation of the National Program for Patient Safety (NPPS), by the Portal GM/MS N. 529, of April 1, 2013 (Brasil, 2013).

Despite the fact that patient safety guidelines in Brazil were initiated in hospital care, possibly due to high technological density and a higher number of unfavorable outcomes and risks to patients, errors and incidents have often occurred in the context of primary care (Aguiar , 2020AGUIAR, T. L. et al. Incidentes de segurança do paciente na Atenção Primária à Saúde de Manaus, AM, Brasil. Interface (Botucatu), v. 24, supl. 1, e190622, 2020. Disponível em: https://doi.org/10.1590/Interface.190622. Acesso em: 12 out. 2023.
https://doi.org/10.1590/Interface.190622... ). Considering the Health Care Networks (HCN), it was within the scope of Primary Health Care (PHC) that the first initiatives of strategies focused on patient safety emerged (Brasil, 2022; Souza , 2019SOUZA, M. M. et al. Patient safety culture in the Primary. Health Care. Rev Bras Enferm., v. 71, n. 1, p. 27-34, 2019. Disponível em: http://dx.doi.org/10.1590/0034-7167-2017-0647. Acesso em: 11 nov. 2023.
http://dx.doi.org/10.1590/0034-7167-2017... ).

The understanding of PHC as a coordinator of care in the country, within the scope of the Unified Health System (SUS), as a preferential gateway for users to the various scenarios of care of the SAR, leveraged the challenge of working with patient safety. Thus, in 2017, from the review of the National Policy on Primary Care (NPPC), were incorporated into its guidelines dimensions of quality and patient safety as an essential and strategic way, determining attributions to all primary care professionals (Brasil, 2017).

The attributes of PHC dialogue with patient safety when knowledge of the territory, epidemiological analysis and situational diagnosis are considered (Araújo , 2019ARAÚJO, L. U. et al. Patient safety in primary health care and polypharmacy: cross-sectional survey among patients with chronic diseases. Rev. Latino-Am. Enfermagem, v. 27, e3217, 2019. Disponível em: http://dx.doi.org/10.1590/1518-8345.3123.3217. Acesso em: 08 dez. 2023.
http://dx.doi.org/10.1590/1518-8345.3123... ). Such facts enable the proper planning of the work process, favor the bond, longitudinality, community and family approach, assist the professional in the integral knowledge of people, in caring with greater assertiveness and protection, in the identification of risks arising from misdiagnosis, drug therapy or unnecessary interventions, constituting a power for patient safety (Nascimento ., 2017NASCIMENTO, R. C. R. M. et al. Polifarmácia: uma realidade na atenção primária do Sistema Único de Saúde. Rev Saude Publica, v. 51, supl. 2, 19s, 2017. Disponível em: https://doi.org/10.11606/S1518-8787.2017051007136. Acesso em: 12 nov. 2023.
https://doi.org/10.11606/S1518-8787.2017... ; Ribeiro , 2021RIBEIRO, H. C. et al. Segurança do doente na atenção primária: percepção de profissionais de equipes de saúde da família. Revista de Enfermagem Referência, v. 5, n. 6, e20082, 2021. Disponível em: https://doi.org/10.12707/RV20082. Acesso: 12 nov. 2023.
https://doi.org/10.12707/RV20082... ).

Safe primary care is essential to achieve universal health coverage (Silva , 2019SILVA, A. P. F. et al. Segurança do paciente na atenção primária: concepções de enfermeiras da estratégia de saúde da família. Rev Gaúcha Enferm., v. 40, n. esp., e20180164, 2019. Disponível em: https://doi.org/10.1590/1983-1447.2019.20180164. Acesso em: 11 nov. 2023.
https://doi.org/10.1590/1983-1447.2019.2... ). Unsafe primary care can cause avoidable harm and injury to patients, unnecessary hospitalizations, overload of other levels of health care, increased costs related to care systems, and in some cases lead to disability and even death (Simplício , 2023SIMPLÍCIO, E. A. et al. Segurança do paciente assistido na atenção primária. Global Clinical Research Journal, [S. l.], v. 3, n. 1, p. e42, 2023. Disponível em: https://globalclinicalresearchj.com/index.php/globclinres/article/view/55. Acesso em: 11 nov. 2023.
https://globalclinicalresearchj.com/inde... ). Thus, patient safety in PHC is justified as a strategy capable of managing risks, maximizing benefits and minimizing long-term harm.

Given the above and considering the importance of the subject, this study, by bibliometric means, sought to map the scientific productions on patient safety in PHC in the Brazilian context. It is considered that the same can contribute to direct the development of knowledge production in this thematic field, which in turn guides health practices.

Method

This is an exploratory, descriptive research supported by bibliometric variables and information provided from a cut of the scientific literature. Bibliometrics consists of performing statistical and measurement analyses, allowing to quantify the written communication process (Barros , 2020BARROS, A. V. M. et al. Levantamento bibliométrico dos artigos publicados na Revista da ABENO no período entre 2001 e 2019. Revista da ABENO, [S. l.], v. 20, n. 2, p. 38-46, 2020. Disponível em: https://doi.org/10.30979/rev.abeno.v20i2.1076. Acesso em: 12 dez. 2023.
https://doi.org/10.30979/rev.abeno.v20i2... ). Thus, through the bibliometric review method, it was sought to ascertain the Brazilian scientific production about Patient Safety in Primary Health Care, between the years 2013 and 2022. The year 2013 was established as an initial time cut due to the regulatory framework of the implementation of NPPS in Brazil.

It is possible to infer that the bibliometric study has as purpose to measure indexes of bibliographic production and scientific contributions on a certain thematic, and while technical, it comprises the reading, the selection, eligibility of content of interest for the research question and study object (Ellegaard; Wallin, 2015ELLEGAARD, O.; WALLIN, J. A. The bibliometric analysis of scholarly production: How great is the impact? Scientometrics, v. 105, n. 3, p. 1809-1831, 2015. Disponível em: https://link.springer.com/article/10.1007/s11192-015-1645-z. Acesso: 12 nov. 2023.
https://link.springer.com/article/10.100... ). Thus, it contributes to the identification of progress in a particular area of knowledge.

To perform the bibliometric technique, a bibliographic search was carried out in the following databases: Scientific Electronic Library Online (SCIELO), Latin-American and Caribbean Literature in Health Sciences (LILACS), Specialized Bibliographical Database in the area of Nursing (BDENF) and Índice Bibliográfico Español en Ciencias de la Salud (IBECS) on 20 June 2023. It is noted that the option for using IBECS, despite being a database that indexes health scientific journals published in Spain, was given because we often find Brazilian research published in Spanish journals.

As a search strategy, descriptors in Portuguese and English were used, from controlled vocabularies extracted from the classification of Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH), respectively: patient safety/patient’s safety; primary health care/primary health care; and for LILACS and IBECS, the terms: seguridad del paciente; atención primaria de salud were used in a complementary way. The Boolean operators AND and OR were used to cross terms in all bases researched, and was considered the time cut (2013-2022), which can be verified in Board 1.

As inclusion criteria for selection of articles, were considered: 1) original research, published in Portuguese, English or Spanish; 2) open access and available in full; 3) articles whose research locus/scenario investigated were in the Brazilian context. All publications were excluded: 1) that did not relate to the object "patient safety in primary health care"; 2) that were outside the established time limit; and 3) manuscripts of the editorial type, comments, reflection, experience report, documentary research and literature review.

The selection of articles included five steps: 1) cross-referencing in databases; 2) application of filters considering inclusion and exclusion criteria; 3) reading the title and abstract, verifying its conformity with the objective of this research; 4) reading the full text of the pre-selected articles to confirm their compatibility with the previously established inclusion criteria; 5) exclusion of repeated articles from databases. The selection steps are expressed in Figure 1.

It should be noted that the Word Cloud technique was used as a support tool in processing information from the keywords of the articles included in this study. The cloud was generated from the Website Word Cloud, highlighting the terms that appeared most frequently.

The analysis and comparison of statistical data took into account the calculation of bibliometric variables that involved numerical quantity and percentage variation, being considered the universal rule for approximation of numerical values to the percentage values. For the compilation of the study material, a matrix was organized in Microsoft Excel (version 2016), from the selected data, with the following information: database and language of publication, title, objective, method, journal, year of publication, number of authors/background of the main author, state/institution of research linkage, descriptors. From this matrix, data were extracted and synoptic analysis tables were constructed.

Regarding the compliance with ethical questions, this study did not need approval in the Ethics Committee, considering that the data collected are in the public domain. It is important to note that this study is part of the doctoral thesis entitled User safety in primary health care: social representations of health workers, within the scope of the Postgraduate Program in Collective Health, at the State University of Feira de Santana, Bahia, Brazil.

Results and Discussion

On the topic of patient safety in PHC, 352 publications were found, summing up the findings from all the databases surveyed (step 1). Of the 28 articles selected (after steps 2, 3 and 4), five were repeated in the databases and were excluded (step 5), thus 23 articles were part of the sample composition of this study and are described in Board 2.

In this selection, on the question "quantitative information regarding the scientific production of articles on patient safety in PHC in the last ten years, between January 2013 and January 2023", 2019 was highlighted, with the highest amount of publications, seven (30.4%), followed by 2021 with four studies (17.4%), 2020 with a total of three (13.05%) and the years 2015, 2016 and 2022 had only two (8.7%) publications (Chart 1).

It is observed that the awareness about patient safety and the increase in scientific production between 2019 and 2022 corroborates the Brazilian regulatory frameworks focused on patient safety in PHC. Although the NPPS was implemented in 2013, only from 2017, with the revision of guidelines for the organization of Primary Care under the Unified Health System (SUS), the NPPS, through Ordinance N 2,436, began to make PHC health workers responsible for the institution of actions for patient safety and adoption of measures aimed at reducing adverse events and risks to users (Brasil, 2017).

As for the regions that published more articles, there is a predominance of publications in the South and Southeast regions (Table 1). The Southeast region with greater expressiveness in scientific production (10), corresponding to 43.5% of the total sample, followed by the South region (8) with 34.8%. The North, Northeast and Midwest regions had lower number of publications. These findings provide subsidies for the recognition that these regions need to develop research aimed at patient safety in APS, in order to guarantee the premises of the NPPS, that aims to contribute to the qualification of health care in all environments where health care takes place (Brasil, 2013).

Regarding the educational organizations that produced more scientific contributions on the subject, federal institutions (13) lead research on the topic, especially Federal University of Rio Grande do Norte (RN) and Federal University of São João Del-Rei (MG), with two articles published each.

In the question "variation of number of authors per article", the highest indices were concentrated in the ranges between 3-4 and 5-6 authors. These variations of intervals were repeated in eight articles, each corresponding to 34.8% of the study sample. Only one scientific production had more than eight authors (12 in total), and was derived from a cross-sectional research, part of the component "Services of the National Research on Access, Use and Promotion of Rational Use of Medicines". It is noted that the predominance of group research, rather than individual, indicates a characteristic of research in the field of health sciences.

When it comes to the training of the main authors, nurses stood out significantly (74%), followed by equivalence between pharmaceutical and nutritionist authors (8.7%), doctors and dentists, with 4.3% (Table 2). No studies with other professional categories were found. These findings point to the need to broaden the scope of publications among professional categories, considering that patient safety should be ensured by all multiprofessional teams involved in PHC, such as physiotherapists, social workers, psychologists.

In the "methodological approaches" question, considering the productions studied, there was a predominance of quantitative studies (48%), followed by qualitative research and mixed studies (quanti-qualitative) both with 26% (Table 3). There was a tendency to carry out quantitative studies associated with cross-sectional cuts, a type of observational study that seeks to collect data to study a population at a certain point in time (Zangirolami-Raimundo; Echeimberg; Leone, 2018). We also verified the use of questionnaires to measure the patient's safety culture in the context of PHC.

In the qualitative studies, the prevalence of descriptive and exploratory methods was observed, possibly in search of the apprehension of non-quantifiable aspects, allowing to understand the phenomenon of patient safety in PHC and its multiple dimensions, considering the complexity of SAR within the SUS. In the mixed studies, it was identified the prevalence of the use of the Delphi technique, often used in processes of validation of protocols, questionnaires, checklist, indicators, which consists of building consensus opinions from a group of experts on certain content, as in the study by Marchon and Mendes Junior (2015MARCHON, S. G.; MENDES JUNIOR, W. V. Tradução e adaptação de um questionário elaborado para avaliar a segurança do paciente na atenção primária em saúde. Cadernos de Saúde Pública, v. 31, n. 7, p. 1395-1402, jul. 2015. Disponível em: https://doi.org/10.1590/0102-311X00157214. Acesso em: 10 out. 2023.
https://doi.org/10.1590/0102-311X0015721... ).

In the question "journal with greater amount of publication", the journals Texto e Contexto Enfermagem (4) and Acta Paulista Enfermagem (4), Quali/Capes A3 and A4, respectively, were highlighted. It is important to highlight that all the journals were in the health area, with expressiveness of publications in nursing field journals. The stratification of the quality of intellectual production of the sample studied can be validated, considering that most articles were published in journals with "A" concept, six of which in journals with Qualis/Capes "A1". It is worth noting that, for the above inferences, the Qualis/Capes classification was considered in the four-year period 2017-2020 (Table 4).

To ensure care in all health facilities of the national territory, the NPPS has created axes that help achieve this objective: Axis 1: The encouragement of a safe practice; Axis 2: Citizen involvement in their safety; Axis 3: Inclusion of patient safety in teaching; Axis 4: The increase in research on patient safety (Brasil 2014). In this direction, the interrelationship between the objects of studies of the sample surveyed and the axes of NPPS (Table 5) was verified, being observed a greater quantity of knowledge productions focused on Axis 1 (38.4%), expanding the dialogue about errors and safe practices.

The object "patient safety culture" was explored in seven studies, and pervades the four axes of the NPPS, corresponding to 30.5% of the publications of the surveyed sample. The safety culture is prioritized by the opportunity to learn from mistakes, without blame or punishment, it is defined as behaviors, skills values and attitudes that guide commitment to safety management, should be stimulated in the processes that encompass all axes of the NPPS (Dal Pai et al., 2020; Galhardi ., 2018GALHARDI, N. M. et al. Avaliação da cultura de segurança do paciente na atenção primária à saúde. Acta Paul Enferm., v. 31, n. 4, p. 409-16, 2018. Disponível em: https://doi.org/10.1590/1982-0194201800057. Acesso em: 10 out. 2023.
https://doi.org/10.1590/1982-01942018000... ; Bezerril et al., 2020).

Studies with objects aimed at measuring damage and validating instruments, which sought to portray evidence or guide safer care, composed the Axis 4 (21.7%) and occupied the third position in the ranking of scientific productions, considering inter-Relationship between the axes of NPPS and objects of selected studies. However, no article was found that fell under Axis 2, suggesting a scientific gap and the need for research that guide professionals to empower users to engage in their own security within SAR, in order to establish a safe link, participatory and co-responsible.

As for the keywords used, in addition to the expressions "patient safety" and "primary health care", the terms "health" and "quality" were highlighted as central elements of the relationships established around the objects of study of the analyzed articles. The keywords expressed in the term cloud acted not only as a gateway to the text, but portray the theme and contents addressed, being observed an approximation of the objects of studies in this bibliometric cut. Among other terms that have strong links with the objects of study, stand out: "assistance"; organizational culture"; "team", "nursing"; "vaccines"; "patient"; "care".

In the bibliometric analysis, three articles with homonymous titles were observed, described as: "Evaluation of the Patient Safety Culture in Primary Health Care", published in different journals, with similar objectives, and that used the same research instrument (Figure 3) See also. There was a trend of studies focused on the measurement of patient safety culture in PHC in different Brazilian regions, which may contribute to strengthen practices, identify potential and challenges, considering the locoregional health context. Both studies used the Medical Office Survey on Patient Safety Culture (MOSPSC), a questionnaire translated and adapted transculturally for Brazil in 2016, entitled "Research on Patient Safety Culture for Primary Care" (Timm; Rodrigues, 2016TIMM, M.; RODRIGUES, M. C. S. Adaptação transcultural de instrumento de cultura de segurança para a atenção primária. Acta Paul Enferm., v. 29, n. 1, p. 26-37, 2016. Disponível em: https://doi.org/10.1590/1982-0194201600005. Acesso em: 10 nov. 2023.
https://doi.org/10.1590/1982-01942016000... ).

Final considerations

This study has made it possible to map the scientific production on patient safety in primary health care over the last ten years, demonstrating research patterns and identifying trends for future academic scientific productions.

Among the types of methodological approaches, there was a predominance of quantitative studies (48%), of the cross-sectional type, being verified expressive quantitative authors nurses (74%). This indicates the need for research by other professional categories, considering that the "safety" dimension should pass through multiprofessional care.

There was a 50% drop in scientific productions between 2021 (17.4%) and 2022 (8.7%), which suggests the need to promote new scientific productions, considering the theme's relevance. The research also contributed to the identification of the objects of study, with emphasis on the culture of patient safety (30.5%) and the identification of trends as to the use of a collection instrument adapted transculturally to the Brazilian reality, that aims to quantify the culture as positive or negative, with reach, if replicated in the various scenarios and providing a national panorama.

With this bibliometric analysis, it was possible to identify the correlation between objects of studies and axes of NPPS. It was observed that the research establishes, more expressively, interface with Axis 1 of NPPS (stimulus to a safe assistance practice), and are aimed at measuring incidents related to patient safety, to safe practices and adherence to recommended recommendations. No studies were found on the patient’s own engagement in their safety, suggesting a gap in this field, which may be significant in the orientation of future production choices.

An approximation of the objects of the sample body studies was verified, from the keywords, with emphasis on the terms "health" and "quality". In addition, it is considered that there is still a need for more investment in the amount of research that portrays state and private universities and the regions North, Northeast and Midwest, to explore the patient safety dimensions in different contexts and regions of the country where primary care is inserted.

References

Publication Dates

History