New challenges in making plans: putting design back into the applied science of planning

The origins of the ‘planning’ lie in the regional sciences and attempts to undertake social engineering of land use occupancy.
Over the last 100 years planning, as a discipline, has variously dabbled in design on the margins with urban design and neourbanism, but has stayed staunchly in the applied science and social science realms. This penchant detrimentally affects its graduates abilities to holistically appreciate and envision the consequences of their decisions-making and plan-making, to convey strength of conviction and expertise to the community, but also to establish a solid basis upon which its professional practice applications and decision-making paradigms successfully articulate equity and comprehensiveness of rational land use and development planning and decision-making. While planning re-learnt how to legitimately evaluate design and aesthetics into planning in the 1960s through the emergent McHargian ecological design paradigm, quickly embracing it as a consequence of major environmental land use disasters that occurred ‘on its watch’ that were demonstrable failures of its claimed insight and professional responsibilities, it has struggled as a discipline to embrace design as an integral technology in its daily operations and expressed ‘territory’ of professional responsibility. This paper reviews this legacy and then charts some emergent patterns in the teaching and practice of planning in Australia that are attempting to re-position design as a legitimate and integral part of the knowledge and skills of a professional planners.

Residential schools in a first-year undergraduate engineering programme

BACKGROUND OR CONTEXT: For over 20 years, Deakin University has delivered an accredited undergraduate engineering course by means of distance education. Prior to 2004, off-campus students were not required to attend classes in person on campus. The course was designed so that the off campus students were able to undertake all study and assessment tasks remotely from the university campus. Offering accredited domestic undergraduate engineering courses via distance education has been seen as an important strategy for helping to provide graduate domestically educated engineers to meet Australia’s current and future needs. From 2000 the Australian accreditation management system for professional engineers, as managed by Engineers Australia, has increased its scrutiny of accredited domestic undergraduate engineering courses that were provided in distance-education mode. This led to a series of policies and recommendations for Australian universities that offer accredited engineering courses in distance-education mode: one of the recommendations was that off campus
enrolled engineering students should periodically attend some campus-based activities throughout the course. During the 2004 accreditation review of engineering courses at Deakin University, the
accreditation panel requested that mandatory campus-based activities be incorporated into the accredited undergraduate engineering course. Specifically the request was that Deakin mandate that all off-campus students enrolled in an accredited undergraduate engineering course provided by university attend in person a residential school at least once during every year of equivalent full-time study load. The accreditation panel suggested a program model for the residential school component of the course as developed by the University of Southern Queensland.
PURPOSE OR GOAL: This paper describes the development of the mandatory residential school component of accredited distance education undergraduate engineering courses at Deakin University with
a particular focus on how the residential school program is implemented at level 1 (first-year full-time equivalent level) of the courses.
APPROACH: To be compliant with accreditation requirements, since 2005 Deakin has conducted residential schools for off-campus students at its Geelong Waurn Ponds Campus. Initially the schools were conducted annually over two-weeks during the first semester, and have transitioned to the current mode where the residential school is conducted as a one week programme in each of the trimesters. During these schools, activities are organised around the respective engineering-course units undertaken by students during the trimester.
DISCUSSION: The minimum requirements for the on-campus components of distance-education-mode accredited engineering courses were developed by Engineers Australia in consultation with members of the Washington Accord (International Education Alliance) and at the time of development, generated considerable debate (Palmer, 2005, 2008). The intended purpose of residential schools was for off-campus enrolled students to have reasonable exposure to a typical “on-the-campus” student experience periodically throughout the course. Elements considered suitable and worthwhile for inclusion in residential school programs included:
• in person engagement with their academic lecturers,
• presentations and interaction with guest speakers from industry,
• industry-based site visits,
• engagement in sole and group-based learning and assessment activities on campus, and
• social interaction with other students.
RECOMMENDATIONS/IMPLICATIONS/CONCLUSION: We have found that advantages to the students who attends a residential school include completing real practical work without the need to assemble their own materials at home, and social engagement with staff and students. Off-campus students leave the residential school with a sense of belonging to a “community”, “one of many doing the same and not the only one”. They have the opportunity to share their often significant professional experience with the generally younger and less experienced on-campus student colleagues. Through this interaction between on-campus and off-campus students, the on-campus students benefit as much as the off-campus students. The disadvantages to the off-campus students is the requirement to travel to Geelong for an extended time, which costs the students both money and time away from work and family. From our experience, we recommend to other institutions starting residential schools of their own that they exploit the mandatory on-campus-presence requirement to enhance learning outcomes, well publicised timetables be available to students before trimester begins (certainly before census date), a standardised academic week during trimester be set for all residential schools, encourage student feedback on the program, and apply a practice of uniformity and consistency in how the programme is managed, especially mandated student attendance. Our residential schools for off-campus-mode students have been running for over 10 years. We have found that the educational and social advantages to the student outweigh the disadvantages.

Tackling risky alcohol consumption in sport: a cluster randomised controlled trial of an alcohol management intervention with community football clubs

BACKGROUND: An increased prevalence of risky alcohol consumption and alcohol-related harm has been reported for members of sporting groups and at sporting venues compared with non-sporting populations. While sports clubs and venues represent opportune settings to implement strategies to reduce such risks, no controlled trials have been reported. The purpose of the study was to examine the effectiveness of an alcohol management intervention in reducing risky alcohol consumption and the risk of alcohol-related harm among community football club members.

METHOD: A cluster randomised controlled trial of an alcohol management intervention was undertaken with non-elite, community football clubs and their members in New South Wales, Australia. Risky alcohol consumption (5+ drinks) at the club and risk of alcohol-related harm using the Alcohol Use Disorders Identification Test (AUDIT) were measured at baseline and postintervention.

RESULTS: Eighty-eight clubs participated in the trial (n=43, INTERVENTION; n=45, CONTROL) and separate cross-sectional samples of club members completed the baseline (N=1411) and postintervention (N=1143) surveys. Postintervention, a significantly lower proportion of intervention club members reported: risky alcohol consumption at the club ( INTERVENTION: 19%; CONTROL: 24%; OR: 0.63 (95% CI 0.40 to 1.00); p=0.05); risk of alcohol-related harm ( INTERVENTION: 38%; CONTROL: 45%; OR: 0.58 (95% CI 0.38 to 0.87); p<0.01); alcohol consumption risk ( INTERVENTION: 47%; CONTROL: 55%; OR: 0.60 (95% CI 0.41 to 0.87); p<0.01) and possible alcohol dependence ( INTERVENTION: 1%; CONTROL: 4%; OR: 0.20 (95% CI 0.06 to 0.65); p<0.01).

CONCLUSIONS: With large numbers of people worldwide playing, watching and sports officiating, enhancing club-based alcohol management interventions could make a substantial contribution to reducing the burden of alcohol misuse in communities.

Engineering education anywhere, anytime: from distance education to blended learning at Deakin University Australia

In 2005 the Sloan Consortium called for engineering education to be available "anywhere, anytime."* Increasing numbers of engineering departments are interesting in offering their programs by means of online learning. These schools grapple with several difficulties and issues associated with wholly online learning: course structure, communication with students, delivery of course material, delivery of exams, accreditation, equity between on-campus and off-campusstudents, and especially the delivery of practical training. Deakin University faced these same challenges when it commenced teaching undergraduate engineering via distance education in the early 1990's. It now offers a fully accredited Bachelor of Engineering degree in both on-campus and off-campus modes, with majors that include civil,mechanical, electrical/electronics, and mechatronics/robotics.This presentation describes Deakin's unique off-campus delivery, students, curricula, approaches to practical work, and solutions to the problems mentioned above. Attendees will experience how Deakin Engineering delivers course materials, communicates with off-campus students, runs off-campus classes, and even delivers lab experience to students living thousands of miles away from the home campus. On display will be experimental lab kits, video presentations, student projects, and online broadcasts of freshman lab experiments. Participants will have the opportunity to see some of these resources hands-on. I will also discuss recent innovations in off-campus delivery ofcourses, including how flipping the classroom has led to blended learning with the on-campus students.Many universities have placed engineering distance education into the too-hard basket. Deakin Engineering demonstrates that it is possible to deliver a full undergraduate degree by means of distance education and online learning, and modern technology makes the job easier than everbefore. The benefits to the professor are many, not the least of which is helping a student living in a remote area or with a full-time job become fully trained and qualified in engineering.

Planning for country: empowering built environment students with Indigenous protocols and knowledge

Increasingly, Built Environment (BE) professionals, including planner, architect and landscape architect practitioners, are becoming involved in the planning and design of projects for, and in direct consultation with Indigenous communities and their proponents. These projects range from inserting Indigenous cultural landscape analysis into planning schemes, including Indigenous protocols and aspirations in policy statements; designing cultural centres, information centres and housing; drafting cultural tourism strategies and devising cross-cultural land management plans. This entails working with Indigenous communities or their nominated representatives as stakeholders in community engagement, consultation, and planning processes. Critically, BE professionals must be able to plan and design with regard to Indigenous community’s cultural protocols, issues and values. Yet many (domestic and or international) students graduate with little or no comprehension of Indigenous knowledge systems or the protocols for engagement with the communities in which they are required to work, whether they be Australian or international Indigenous communities. Contextually, both PIA and the planning academe have struggled with coming to terms with this realm over the last 10 years. This paper will report on a recently completed Australian Government Office of Learning & Teaching (OLT) funded research project that has sought to improve opportunities to improve the knowledge and skills of tertiary students in the BE professions through the enhancement of their competency, appreciation and respect for Indigenous protocols and processes that also implicates the professional accreditation systems that these courses are accountable. It has proposed strategies and processes to expose students in the BE professions to Australian Indigenous knowledge and cultural systems and the protocols for engaging with Indigenous Australians about their rights, interests, needs and aspirations. Included in these findings is the provision of a tool that enables and offers guidance to BE tertiary students and academics how to enhance comprehension, exposure to, and knowledge and cultural systems of, Indigenous Australians. While the scope of this report is cross-BE, this paper will focus upon the planning practice, policy and academe realms.

Online education, accrediting standards, and student success: An examination of the relationship between the southern association of colleges and schools commission on colleges standards for online education and student success

Prior to 2000, there were less than 1.6 million students enrolled in at least one online course. By fall 2010, student enrollment in online distance education showed a phenomenal 283% increase to 6.1 million. Two years later, this number had grown to 7.1 million. In light of this significant growth and skepticism about quality, there have been calls for greater oversight of this format of educational delivery. Accrediting bodies tasked with this oversight have developed guidelines and standards for online education. ^ There is a lack of empirical studies that examine the relationship between accrediting standards and student success. The purpose of this study was to examine the relationship between the presence of Southern Association of Colleges and Schools Commission on College (SACSCOC) standards for online education in online courses, (a) student support services and (b) curriculum and instruction, and student success. An original 24-item survey with an overall reliability coefficient of .94 was administered to students (N=464) at Florida International University, enrolled in 24 university-wide undergraduate online courses during fall 2014, who rated the presence of these standards in their online courses. The general linear model was utilized to analyze the data. The results of the study indicated that the two standards, student support services and curriculum and instruction were both significantly and positively correlated with student success but with small R2 and strengths of association less than .35 and .20 respectively. Mixed results were produced from Chi-square tests for differences in student success between higher and lower rated online courses when controlling for various covariates such as discipline, gender, race/ethnicity, GPA, age, and number of online courses previously taken. A multiple linear regression analysis revealed that the curriculum and instruction standard was the only variable that accounted for a significant amount of unique variance in student success. Another regression test revealed that no significant interaction effect exists between the two SACSCOC standards and GPA in predicting student success. ^ The results of this study are useful for administrators, faculty, and researchers who are interested in accreditation standards for online education and how these standards relate to student success.^

Initial teacher education and assessment of graduates in Australia

In this chapter we discuss the impact of recent standards-based legislation and implementation in Australia designed to improve the quality of teacher education and examine the ways in which teacher educators are assessing graduates in relation to beginning teacher standards, the evidence they are using within the context of accreditation of their programs, and the impact this is having on the teacher education curriculum. We report on research into the implementation and evaluation of an authentic teacher assessment approach being used in one Australian university and argue that such an approach not only empowers pre-service teachers but also teacher educators.

The influence of eco-label knowledge and trust on pro-environmental consumer behaviour in an emerging market

Consumers are increasingly concerned about the negative environmental implications of purchasing goods, which in turn shape their behaviour. Yet, there are indications that consumers do not always act on these concerns, causing an attitude–behaviour gap. For consumers to make ecologically responsible purchases, they need relevant product environmental information. Therefore, marketers and firms are increasingly integrating more detailed environmental information in their offerings, including eco-labels with externally validated information. This study integrates consumers’ knowledge and trust in eco-labels with their environmental knowledge to determine how these affect pro-environmental consumer behaviour (PECB). The findings suggest environmental and eco-label knowledge is positively associated with attitudes towards the environment, and that positive environmental attitudes and trust in eco-labels affect PECB. This implies that firms, policy-makers and accreditation organisations (i.e. labelling) can educate consumers about eco-labels and the environment to increase PECB. Such strategies will also build consumer knowledge and trust in eco-labels, necessary for facilitating PECB.

Assessment of credit arrangements towards engineering programs/courses

Credit Transfer (CT), Advanced Standing (AS), Credit for Prior Learning (CPL), Recognition of PriorLearning (RPL), Prior Learning Assessment and Recognition (PLAR), Accreditation of PriorExperiential Learning (APEL), Validation of Prior Learning (VPL), Prior Learning Assessment (PLA),Credit Transfer and Recognition (CTR), Recognition of Current Competency (RCC) and Credit forConcurrent Formal Learning (CCFL) are the terms used by academic institutions and engineeringschools to describe several types of credit arrangements depending upon a student’s current state ofqualification, experience, skills and knowledge towards the requirement of his/her formal professionalengineering qualification. The objectives of such credit arrangements are to make sure that thelearning is not duplicated, to reduce the duration and cost of the engineering studies, to encourageworking engineering associates and technologists return to engineering schools for professionalengineering qualification and to help upgrade the skills and knowledge of the junior engineeringpractitioners, to name a few. Formal, informal, non-formal or a combination of prior learning are usedfor such credit arrangements. Engineering schools offer block credit, specified credit, unspecifiedcredit and a combination of these forms of credits when recognising prior learning of any form.However, anecdotal and literature evidence suggests that the assessment of credit arrangementslacks established universal framework for assessment, lacks harmonisation, compatibility,transparency and comparability and is complex and inconsistent resulting a significant variations in theassessment for recognising prior learning across engineering schools in spite of being based onsimilar fundamental principles. There is a clear need of a consolidated framework in order to assesscredit arrangements systematically and consistently.PURPOSEThe purpose of this study is to develop a consolidated framework for assessing credit arrangementstowards a partial requirements of a professional engineering course, program, degree or qualification.The developed framework is expected to help manage the assessment of credit arrangement process.APPROACHThis study first critically reviews existing frameworks and literature evidences regarding the principlesof credit arrangements towards a partial requirements of a professional engineering course, program,degree or qualification. This study then uses evidence-based literature knowledge (principles,processes and practices) to devise a consolidated framework for assessing credit arrangements. Theframework is then expanded in order to elaborate its several components.RESULTSThe existing frameworks and literature review suggest that for better assessment of creditarrangements, attentions are to be given on the forms of prior learning, types of credit arrangements,forms of credit recognition, required documents, characteristics of the prior learning, alignment of priorlearning with professional engineering qualification and additional aspects.CONCLUSIONSAs the assessment of credit arrangements has been a major challenge for engineering schools, theframework developed in this study is expected to help engineering schools to manage the assessmentprocess systematically and consistently. For further study, the framework needs to be continuouslyimplemented, monitored and evaluated.

Re-casting terra nullius design-blindness: better teaching of indigenous knowledge and protocols in Australian architecture education

This paper reviews the current status and focus of Australian Architecture programs with respect to Indigenous Knowledge and the extent to which these tertiary programs currently address reconciliation and respect to Indigenous Australians in relation to their professional institutions and accreditation policies. The paper draws upon the findings of a recently completed investigation of current teaching: Re-Casting terra nullius blindness: Empowering Indigenous Protocols and Knowledge in Australian University Built Environment Education. Three data sets from this investigation are analysed: a desktop survey of Australian Built Environment curricula; workshops with tertiary providers and students, professional practitioners and representatives of three Built Environment professional institutes; and an online survey of Australian Built Environment students (of which their discipline could be isolated) ascertaining what is currently being taught and learned and what changes would be feasible within the constraints of courses from their perspective. Detailed descriptions are also provided of pedagogic improvements informed by the project findings. The findings suggest minimal current exposure of Architecture students to Indigenous Knowledge content beyond voluntary engagement in self-chosen thesis projects and elective (including studio) subjects led by passionate but largely unsupported teachers championing Indigenous issues; a paucity of teaching echoed by practitioners and accreditors who acknowledge lack of expertise in this area across the profession. This paper discusses ways in which Indigenous Knowledge might be better acknowledged, respected and introduced to Australian Architecture students’ education. Also discussed are teaching strategies with global relevance.

Medición de la cultura de seguridad del paciente en un hospital público de primer nivel en el municipio de Villeta

Esta investigación midió la percepción del personal asistencial sobre la cultura de seguridad de los pacientes en un hospital de primer nivel de complejidad por medio de un estudio descriptivo de corte transversal. Se utilizó como herramienta de medición la encuesta ‘Hospital Survey on Patient Safety Cultura’ (HSOPSC) de la Agency of Healthcare Research and Quality (AHRQ) versión en español, la cual evalúa doce dimensiones. Los resultados mostraron fortalezas como el aprendizaje organizacional, las mejoras continuas y el apoyo de los administradores para la seguridad del paciente. Las dimensiones clasificadas como oportunidades de mejora fueron la cultura no punitiva, el personal, las transferencias y transiciones y el grado en que la comunicación es abierta. Se concluyó que aunque el personal percibía como positivo el proceso de mejoramiento y apoyo de la administración también sentía que era juzgado si reportaba algún evento adverso.

Modelo de evaluación de aprendizajes como estrategia de fortalecimiento del Sistema Integral de Gestión de la Calidad de la universidad: una mirada desde lo institucional a lo individual como miembro de la comunidad académica

"El siguiente texto tiene como propósito inicial hacer una reflexión de lo general a lo particular desde la visión de un modelo de aseguramiento de la calidad de las universidades, en el marco de la evaluación de los aprendizajes, en busca de hacer un seguimiento real al proceso de formación del estudiante, durante su ciclo académico que debería mostrar una sólida transformación intelectual y de desarrollo personal. En otras palabras, dar cuenta del cumplimiento de una de las principales funciones del quehacer universitario que consiste en enseñar a los estudiantes para que aprendan y desarrollen habilidades y competencias necesarias para interactuar de manera eficiente en una sociedad del conocimiento orientada al desarrollo y beneficio social común. Esto desde una perspectiva institucional, para posteriormente ir hasta el aula y los cursos que orienta el profesor, con el fin de resaltar la importancia de los elementos que debe contemplar la evaluación como parte del proceso de aprendizaje y de esta manera dejar en el ambiente una de las medidas más importantes y pertinentes de calidad en la educación universitaria. Es relevante aclarar que aunque en numerosos apartados del documento se amplía el espectro a la educación superior, el énfasis del texto se centra en el entorno educativo universitario."--Introducción.

Modelo de gestión para la atención integral de pacientes con enfermedades huérfanas o raras en Colombia

Las enfermedades raras o huérfanas corresponden a aquellas con baja prevalencia en la población, y en varios países tienen una definición distinta de acuerdo con el número de pacientes que afectan en la población. La Organización Mundial de la Salud (OMS), las define como un trastorno que afecta de 650 a 1.000 personas por millón de habitantes, de las que se han identificado alrededor de 7.000. En Colombia su prevalencia es menor de 1 por cada 5.000 personas y comprenden: las enfermedades raras, las ultra-huérfanas y las olvidadas. Los pacientes con este tipo de enfermedades imponen retos a los sistemas sanitarios, pues si bien afectan a un bajo porcentaje de la población, su atención implica una alta carga económica por los costos que involucra su atención, la complejidad en su diagnóstico, tratamiento, seguimiento y rehabilitación. El abordaje de las enfermedades raras requiere un manejo interdisciplinar e intersectorial, lo que implica la organización de cada actor del sistema sanitario para su manejo a través de un modelo que abraque las dinámicas posibles entre ellos y las competencias de cada uno. Por lo anterior, y teniendo en cuenta la necesidad de formular políticas sanitarias específicas para la gestión de estas enfermedades, el presente trabajo presenta una aproximación a la formulación de un modelo de gestión para la atención integral de pacientes con enfermedades raras en Colombia. Esta investigación describe los distintos elementos y características de los modelos de gestión clínica y de las enfermedades raras a través de una revisión de literatura, en la que se incluye la descripción de los distintos actores del Sistema de Salud Colombiano, relacionados con la atención integral de estos pacientes para la documentación de un modelo de gestión integral.

Implementação da metodologia de cuidados Humanitude

Objectives: To implement Humanitude Care Metodology in the context the teaching and care practice. Relevance and impact of the project Training nursing students in Clinical Practice to develop skills of relationship and communication through the appropriation of Humanitude Care Methodology; Implementation and dissemination of Humanitude Care Methodology in care units; Creating a reference framework for humanized care, evaluation of its effectiveness and accreditation. Productivity/Main Achievements Organization of International Conferences and workshop Education course in Humanitude lectured to the ESEnfC teachers 7 oral scientific presentations in international health congresses with abstracts published on indexed journals 5 book publications

Erro de medicação: circunstâncias da sua ocorrência na perspetiva do enfermeiro.

Introdução Nas últimas décadas tem-se assistido a uma vertiginosa evolução tecnológica, particularmente na área da saúde, proporcionando ganhos em saúde e aumentando as expectativas dos utilizadores dos cuidados de saúde. Na complexa interação Homem e tecnologia que ocorre durante a prestação de cuidados existe o risco associado, que poderá levar à ocorrência de erros em saúde e, neste caso, os cuidados de saúde não só não trarão os esperados benefícios para o doente como poderão provocar o dano Fragata e Martins (2004). Assim, o tema da segurança dos doentes, principalmente o erro em saúde, ganha importância dentro do sector da saúde. O erro relacionado com a medicação, é considerado uma das principais causas de morte e incapacidade, falecendo mais pessoas devido a erros de medicação do que a acidentes de trabalho (Khon, Corrigan e Donaldson, 2000). Embora a gestão da medicação envolva múltiplos profissionais, os enfermeiros assumem, neste contexto, um papel central na promoção da segurança dos doentes, quer na deteção de falhas ocorridas anteriormente com o doente, quer na prevenção de falhas durante as fases do processo em que intervêm diretamente (Catela, 2008). No sentido de reduzir os eventos adversos relacionados com a medicação é essencial adotar uma postura de compreensão do erro, dos fatores precipitantes e circunstanciais do mesmo. Esta postura será o primeiro passo para sua prevenção. Porém, reconhece-se que existe subnotificação dos eventos adversos, nomeadamente os relacionados com a medicação, o que tem dificultado o conhecimento desta realidade. Objetivos O estudo propõe-se concretizar os seguintes objetivos gerais: compreender as circunstâncias associadas ao erro de medicação e sensibilizar a equipa de enfermagem para a importância do relato do erro de medicação. Dos objetivos gerais emergiram os seguintes objetivos específicos: identificar os diferentes tipos de erro de medicação; identificar o impacto do erro no doente, na organização e no profissional; identificar o contexto da sua ocorrência (profissionais envolvidos e momento do dia); identificar as fases do processo em que ocorrem os erros de medicação; compreender as causas precipitantes do erro de medicação (falhas humanas ou falhas sistémicas); identificar as medidas de mitigação de dano realizadas pelos profissionais; identificar as medidas preventivas propostas pelos profissionais; verificar se ocorreu a notificação do erro e analisar os fatores que dificultam ou facilitam a decisão de notificar o erro Metodologia O presente estudo procura dar resposta à questão de investigação "Quais as circunstâncias que envolvem a ocorrência dos erros de medicação, vivenciados pelos enfermeiros, num serviço de internamento de um hospital central?" Nesse sentido desenhou-se um estudo transversal, descritivo, exploratório, numa abordagem qualitativa, que permita a compreensão do fenómeno. Foram convidados a participar no estudo os enfermeiros que trabalham num serviço de internamento do Hospital Central. Cumpridos os critérios de inclusão, aceitaram participar onze informantes. Optou-se pela técnica de entrevista semi-estruturada. O participante foi convidado a relatar uma situação de erro de medicação vivenciado ou observado. A fim de facilitar o relato dos participantes, o guião de entrevista seguiu omodelo Patient Safety Event Taxonomy (PSET) da Join Commission Accreditation Health Organization (JCAHO), adaptado por Castilho e Parreira (2012) para o estudo de eventos relacionados com a prática de enfermagem, permitindo organizar a informação em torno de cinco eixos temáticos: tipo de evento, impacto, domínio, causa, mitigação e prevenção do dano e notificação. Resultados/Discussão Os enfermeiros relatam essencialmente situações incidentes com a medicação vivenciados por si e reconhecem situações near miss como precursor de um possível evento adverso. Os eventos adversos ocorrem principalmente na fase de administração e envolvem principalmente situações de troca de doentes. No que concerne ao impacto que estes eventos adversos podem provocar no doente verifica-se que existe uma tendência geral para a sua desvalorização, considerando os profissionais que não houve impacto negativo ou este foi mínimo. Associam este resultado ao predomínio de medicação oral. Relativamente ao impacto para o Organização, identificamos uma tendência de não valorização, no entanto alguns enfermeiros identificam os gastos materiais, em recursos humanos (novas preparações e aumento da vigilância) e na imagem, quer junto do doente quer da família. Nas consequências para o enfermeiro valorizam sobretudo o impacto negativo (culpa, vergonha, ansiedade), identificando também a oportunidade de aprendizagem. A análise das causas permite evidenciar que os erros acontecem em resultado do entrelaçar de vários fatores humanos e sistémicos que contribuem para a sua ocorrência. As pessoas falham: violam métodos de trabalho preconizados e regras de segurança que conhecem, esquecem-se, enganam-se e confundem-se. As situações de erro são justificadas pelos enfermeiros pela existência de um ambiente que é propiciador da ocorrência destas situações, que favorece a distração, a desconcentração e promove a violação do método individual de trabalho, numa tentativa de contornar o elevado volume de trabalho a fim de dar resposta em tempo útil às necessidades dos doentes. Os enfermeiros, quando referiram como causa uma distração, na sua maioria souberam atribuir a causa dessa mesma distração e não a aceitaram apenas por si só. Foram identificados como fatores que dificultam o trabalho dos enfermeiros e potenciam a ocorrência do erro, o elevado volume de trabalho, as múltiplas interrupções a que são sujeitos aquando da preparação e administração de fármacos, a confusão, a agitação e elevado número de pessoas (utentes e visitas) a circular no serviço e na zona de preparação de fármacos aquando da preparação, a ausência de material atualizado e ajustado a uma preparação e administração segura e condições arquitetónicas da zona de preparação pouco adequadas, Foram ainda, referidas a inadequação do aplicativo informático, o sistema de registo de medicação não dispõe de mecanismos seguros para evitar os erros e o facto de nem todos as camas disporem de rampas de oxigénio. Ainda que os enfermeiros tenham identificado falhas humanas e sistémicas na ocorrência do erro, defenderam que na sua maioria são propiciadas por um sistema frágil e propiciador dessas mesmas falhas. Os enfermeiros vivenciam o erro com responsabilidade, adotando de imediato estratégias de redução do dano, nomeadamente aumentando a vigilância, a certificação de ausência de alergia e aumento da pesquisa sobre ao fármaco A oportunidade de refletir sobre as circunstâncias que envolveram o erro de medicação deu origem a várias sugestões de melhoria no serviço, nomeadamente o aumento da dotação de profissionais, a existência de um armário com sistema de unidose, o cumprimento do método individual de trabalho em especial no que concerne à gestão do medicamento, a otimização do aplicativo informático de gestão do medicamento, a otimização na identificação do doente em cada unidade, maior concentração aquando da preparação e administração dos medicamentos, a existência de um espaço físico exclusivo para a preparação da medicação, a existência de rampas de oxigénio em todas as unidades e a criação de momentos de partilha em equipa a fim de estimular a aprendizagem com erro. Os profissionais reconhecem importância da notificação e da aprendizagem com o erro, sobretudo nos casos graves. Identificam como fatores que e contribuem para a não notificação, o medo de penalização, assim como, o desconhecimento da forma como proceder para notificar o evento adverso. Perante tais achados sugere-se, tal como preconiza Chiang, Hui-Ying e Pepper (2006), que será importante trabalhar juntamente com estes enfermeiros no sentido de os formar e informar sobre onde e como notificar, reforçar a extrema importância de notificar desmitificando o receio da punição individual, estimulando a cultura de aprendizagem com o erro em detrimento de uma culpabilização individual. Conclusão A segurança do doente apresenta-se como uma questão incontornável da qualidade em saúde, reconhecendo-se, que apesar dos avanços tecnológicos e científicos, continuam a ocorrer erros nas práticas profissionais, nomeadamente erros de medicação, suscetíveis de causar dano ao doente. Os profissionais reconhecem que este são frequentemente evitáveis, identificam diferentes fatores humanos e sistémicos que intervêm na sua ocorrência. Os enfermeiros apresentaram como medidas preventivas de erros o aumento da dotação de profissionais, a existência de um armário com sistema de unidose, o cumprimento do método individual de trabalho, em especial no que concerne à gestão do medicamento, a otimização do aplicativo informático de gestão do medicamento, a otimização na identificação do doente em cada unidade, maior concentração aquando da preparação e administração dos medicamentos, a existência de um espaço físico exclusivo para a preparação da medicação, a existência de rampas de oxigénio em todas as unidades e a criação de momentos de partilha em equipa a fim de estimular a aprendizagem com erro. Os resultados desta investigação foram apresentados e discutidos em equipa sendo assim criado um espaço de reflexão. Espera-se com este trabalho estimular a reflexão em equipa sobre esta temática, contribuir para a redução do erro de medicação e fomentar uma cultura de notificação de eventos adversos. É fundamental incutir nos profissionais e nas organizações uma verdadeira cultura de segurança, que proceda à gestão do risco clínico.. Tal como Fragata (2010), consideramos que a segurança dos doentes será tanto mais eficaz quanto mais robusto for o sistema.