Segurança do paciente em imunizações : vacinação segura da teoria à prática.

Abstract

Despite of all the benefits given to the vaccinate strategies, of the advance at the vaccine improvement more immunogenic and less reatogenic, the immunobiological are not innocuous products, it can produce adverse events expected and not expected originated from failures at the production, conservation, manipulation and administration or just because of its intrinsic characteristics. The PNI (National Program of Immunization) extended in a significant way the number of immunobiological and the beneficiary public of vaccination. In this way, the volume and the complexity of the activities got intensify. The vaccinators, supervised by nurses, should guarantee the quality of the immunization activities. This study wanted to know security aspects of the patient in immunizations in concerning to the AEFI (adverse events following immunization), the programmatic mistakes and the knowledge and difficulties of the vaccinators. To do that, was used a quantitative descriptive exploratory approach. The documental research was based on 162 notifications of mistakes and AEFI from 2014 to 2016 of a CRS of the state of Rio Grande do Sul. The field research was based on two different knowledge tests, made by 35 vaccinators of the head office city of the CRS. RESULTS: low incidence of mistakes and AEFI with mistakes rates of 2/10.000 and AEFI rates of 5/10.000 applied doses. The more frequent mistakes came from the VOP (20,8%) and the pentavalent vaccine (12%) applied with the validity expired (27%) due from the inattention of the vaccinator (62,5%). The AEFI more notified was fever (38,4%), the vaccine more frequent the pentavalent (18,9%) and 57% of the AEFI occurred after the first dose. The successes average of the vaccinators at the first test was 70% and at the second test was 82% (nurses) and 93% (nurse technician). They showed fragility at their knowledge about AEFI expected and not expected of the vaccines BCG and pentavalent and the most of them believe that there is underreporting of programmatic mistakes. The nurses have to assume their technic responsibility in immunizations, providing more competence to the vaccinators ensuring a safer vaccination for the population.