Quaternary prevention and patient safety in Brazil
The concept of quaternary prevention was proposed by Jamoule1, who took under
consideration the classical context of three levels of prevention: primary, secondary and tertiary prevention2. For the author, quaternary prevention is the fourth and last type of health prevention and is related to the risk of iatrogenic disease, that is, those caused by inappropriate healthcare, such as excessive diagnostic and therapeutic interventionism, in addition to excessive medication1.Quaternary prevention, in a broad conception, should be an action that mitigates or avoids the consequences of excessive interventionism in healthcare, particularly unnecessary activities
that may cause adverse events3. It is based on two essential principles: proportionality, such
that the benefits of health interventions should outweigh the risks; and precaution, based on
Hippocrates’ precept primum non-nocere, that is, ‘first, do not harm’. These two principles are
well known among researchers and scholars interested in patient safety, risk management, and
pharmacosurveillance, but they are not usually connected with one another. There has been, in the last decade, an explosion of studies addressing iatrogenesis in hospitals, especially medication errors. These studies usually report health incidents like adverse events and potential adverse events4. These reported data are very useful and should be utilized not only to acknowledge the problem but mainly to implement preventive measures to avoid new incidents, given there is such a high occurrence of avoidable adverse events in Brazilian hospitals: about 67% of all adverse events are avoidable events5. This information was published in an important periodical, The Lancet, which exclusively addressed Brazilian healthcare, showing there is much to be done in order for the ancient concept of quaternary prevention to be applied; there is much to be done to avoid potentially harmful health incidents among patients. In order to change this context, the first step is to recognize that incidents do happen. There is still much difficulty, on the part of Brazilian facilities, in acknowledging their weaknesses and working on quaternary prevention, managing risks to avoid harmful incidents or adverse events4. A large proportion of Brazilian hospitals still does not correctly evaluate their work processes or choose appropriate indicators. Even when they do, there is difficulty in promoting conflictfree assessments and assuming responsibility for continuous quality improvement in which the patient is the focus of the discussion. To ensure the production of information to support decision-making and the commitment to quality improvement among health facilities, it is essential to invest in the development of existing local capacities and information systems6. For that, autonomy and proactivity should be promoted among health facilities. Health institutions should implement internal improvement measures in order to promote patient safety and improve the quality of care delivery even before governmental agencies reach a decision concerning incidents reported. Therefore, health facilities should practice quaternary health prevention to avoid further incidents.
Three important tools should be combined in the practice of quaternary prevention: a
patient-centered approach, evidence-based practice, and the centralization of care at the primary
health care level7. This type of prevention transverses all levels of healthcare, since iatrogenesis and individuals at risk of excessive treatment are observed in all levels. In this context, Brazilian health managers should systematically identify the incidents occurring in the care delivered to patients, in both public and private facilities, rather than.
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