Recommendations for promoting patient safety and quality of care in the prison system: an integrative review
DOI:
https://doi.org/10.21527/2176-7114.2026.51.16846Keywords:
Patient Safety, Prisons, Quality Indicators in Health Care, NursingAbstract
Health incidents occurring in the prison system are not uncommon, and patient safety remains under-theorized in extra-hospital settings. The objective of this study was to identify, in the literature, recommendations for promoting patient safety and quality of care in the prison system. An integrative review was conducted in January 2024 using the BDENF, IBECS, LILACS, MEDLINE, and SciELO databases, including publications up to the year 2023. Of the 185 articles initially identified, 20 were included in the analysis. Nineteen recommendations were synthesized to promote safety and quality of health care in the prison context, highlighting access for persons deprived of liberty to health services, multidisciplinary team, and early diagnosis of diseases and health conditions; control and supervision of the medication management process; professional training and education; adequate health workforce staffing; development of guidelines and policies; and risk management. The identified actions, when applied in practice, may contribute to the quantitative and qualitative advances necessary to provide value-based care to persons deprived of liberty and to meet the principles of the Sustainable Development Goals.
References
1. Astier-Peña MP, Martínez-Bianchi V, Torijano-Casalengua ML, Ares-Blanco S, Bueno-Ortiz JM, Férnandez-García M. The Global Patient Safety Action Plan 2021-2030: Identifying actions for safer primary health care. Aten Primaria. 2021;53 Suppl 1(Suppl 1):102224. DOI: https://doi.org/10.1016/j.aprim.2021.102224
2. Brasil. Ministério da Saúde. Documento de referência para o Programa Nacional de Segurança do Paciente. Ministério da Saúde; Fundação Oswaldo Cruz; Agência Nacional de Vigilância Sanitária. Brasília : Ministério da Saúde, 2014.
3. Fair H, Walmsley R. World Prison Population List [Internet]. 13. Ed. London, ICPR, 2021 [citado 15 nov. 2023]. Disponível em: https://www.prisonstudies.org/sites/default/files/resources/downloads/world_prison_population_list_13th_edition.pdf
4. Rossetto M, Alves CGR, Drechsler G, Kuerten LF, Souza RM, Batista, JL. Olhar profissional no atendimento em saúde às pessoas privadas de liberdade: revisão integrativa. Trab. Educ. Saúde (Online). 2022; 20: e00909197. DOI: https://doi.org/10.1590/1981-7746-ojs909
5. Brasil. Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas, Coordenação de Saúde no Sistema Prisional. 1. ed. Brasília: Ministério da Saúde, 2014.
6. Robertson H, Debono DF, Travaglia J. Patient Safety and People Who Are Incarcerated [Internet]. Contemporary Topics in Patient Safety, volume 2. IntechOpen; 2023 [citado 12 mar. 2024]. DOI: http://dx.doi.org/10.5772/intechopen.108942
7. McFadzean IJ, Davies K, Purchase T, Edwards A, Hellard S, Ashcroft DM, et al. Patient safety in prisons: a multi-method analysis of reported incidents in England. J R Soc Med. 2023; 116(7):236-245. DOI: https://doi.org/10.1177/01410768231166138
8. Institute of Global Health Innovation. National State of Patient Safety 2022: What we know about avoidable harm in England [Internet]. Imperial College London; 2022 [citedo 15 mai. 2024]. Disponível em: https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/National-State-of-Patient-Safety-2022.pdf
9. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008; 17(4):758-764. DOI: https://doi.org/10.1590/S0104-07072008000400018
10. Ursi ES, Galvão CM. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. Rev Latino-am Enfermagem. 2006;14(1):124–131. DOI: https://doi.org/10.1590/S0104-11692006000100017
11. Melnyk BM, Fineout-Overholt E. Evidence-basedpractice in Nursing & Healthcare: a guide to bes tpractice. 4nd ed. Philadelphia (US): WoltersKluer; 2019
12. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:71. DOI: https://doi.org/10.1136/bmj.n71
13. Khairat S, Zebrowski A, Stabile K, Bohlmann A, Wallace E, Yao Y, et al. Assessment of Stakeholder Perceptions and Cost of Implementing a Telemedicine Specialty Program at Correctional Facilities in North Carolina. Perm J. 2023; 27(3):49-59. DOI: https://doi.org/10.7812/TPP/22.167
14. Little S, White B, Moensted M, Butler K, Howard M, Roberts J, et al. Health and correctional staff acceptability of depot buprenorphine in NSW prisons. Int J Drug Policy. 2023; 114:103978. DOI: https://doi.org/10.1016/j.drugpo.2023.103978
15. Keers RN, Wainwright V, McFadzean J, Davies K, Campbell SM, Stevenson C, et al. Defining avoidable healthcare-associated harm in prisons: A mixed-method development study. PLoS One. 2023;18(3):e0282021. DOI: https://doi.org/10.1371/journal.pone.0282021
16. Oladeru OT, Lam CM, Qureshi MM, Hirsch AE, Mak KS, Dyer MA, et al. Inequalities in Cancer Stage at Diagnosis Among Incarcerated Individuals Undergoing Radiation Therapy at a Large Safety-Net Hospital. Int J Radiat Oncol Biol Phys. 2023;116(1):194-198. DOI: https://doi.org/10.1016/j.ijrobp.2023.02.002
17. Rosen DL, Blue C, Brown M, Bradley-Bull S, DiRosa EA, Carda-Auten J. The role of detention officers in the provision of jail healthcare in the Southeastern United States. Soc Sci Med. 2023; 330:116065. DOI: https://doi.org/10.1016/j.socscimed.2023.116065
18. Burton J. The emergence of custodial health nursing as a specialty whose time has come: An Australian experience. Int Nurs Rev. 2023;70(3):273-278. DOI: https://doi.org/10.1111/inr.12815
19. Magola-Makina E, Abuzour AS, Ashcroft DM, Dunlop J, Brown P, Keers RN. Exploring the challenges to safer prescribing and medication monitoring in prisons: A qualitative study with health care staff. PLoS One. 2022;17(11):e0275907. DOI: https://doi.org/10.1371/journal.pone.0275907
20. Barcella RC, Ely KZ, Krug SBF, Possuelo LG. Planificação da Atenção Primária à Saúde nas prisões: projeto piloto. Saude e pesqui. 2022; 15(2): e10366. DOI: https://doi.org/10.17765/2176-9206.2022v15n2.e10366
21. Abuzour AS, Magola-Makina E, Dunlop J, O'Brien A, Khawagi WY, Ashcroft DM, Brown P, Keers RN. Implementing prescribing safety indicators in prisons: A mixed methods study. Br J Clin Pharmacol. 2022; 88(4):1866-1884. DOI: https://doi.org/10.1111/bcp.15107
22. Nowotny KM, Kuptsevych-Timmer A, Oser C. Criminal Justice Contact and Health Service Utilization among Women across Health Care Settings: Analyzing the Role of Arrest. Womens Health Issues. 2019;29(2):125-134. DOI: https://doi.org/10.1016/j.whi.2018.12.005
23. Barrera-Valencia C, Benito-Deviab AV, Vélez-Álvarezc C, Figueroa-Barrerad M, Franco-Idárraga SM. Costo-efectividad de telepsiquiatría sincrónica frente a asincrónica para personas con depresión privadas de la libertad. Rev.colomb.psiquiatr. 2017; 46(2):65-73. DOI: https://doi.org/10.1016/j.rcp.2016.04.008
24. Wong I, Wright E, Santomauro D, How R, Leary C, Harris M. Implementing two nurse practitioner models of service at an Australian male prison: A quality assurance study. J Clin Nurs. 2018;27(1-2):e287-e300. DOI: https://doi.org/10.1111/jocn.13935
25. Meroueh F, Lardeur JY, Lapostolle F. Prisons are at highest risk of death by fire and smoke exposure. Injury. 2017;48(3):791. DOI: https://doi.org/10.1016/j.injury.2017.01.012
26. Goldstein MM. Health information privacy and health information technology in the US correctional setting. Am J Public Health. 2014;104(5):803-9. DOI: https://doi.org/10.2105/AJPH.2013.301845
27. Phillips A. Prescribing in prison: complexities and considerations. Nurs Stand. 2014;28(21):46-50. DOI: https://doi.org/10.7748/ns2014.01.28.21.46.e8434
28. Deslich SA, Thistlethwaite T, Coustasse A. Telepsychiatry in correctional facilities: using technology to improve access and decrease costs of mental health care in underserved populations. Perm J. 2013;17(3):80-6. DOI: https://doi.org/10.7812/TPP/12-123
29. Hassan L, Weston J, Senior J, Shaw J. Prisoners holding their own medications during imprisonment in England and Wales: a survey and qualitative exploration of staff and prisoners' views. Crim Behav Ment Health. 2012;22(1):29-40. DOI: https://doi.org/10.1002/cbm.822
30. Stern MF, Greifinger RB, Mellow J. Patient safety: moving the bar in prison health care standards. Am J Public Health. 2010;100(11):2103-10. DOI: https://doi.org/10.2105/AJPH.2009.184242
31. Diuana V, Lhuilier D, Sánchez AR, Amado G, Araújo L, Duarte AM, et al. Health in the prison system: representations and practices by prison guards in Rio de Janeiro, Brazil. Cad. Saúde Pública. 2008; 24(8):1887-1896. DOI: https://doi.org/10.1590/s0102-311x2008000800017
32. Aguiar, RS Silva, HS. Segurança do paciente na atenção primária à saúde: uma reflexão teórica. Saúde Coletiva (Barueri). 2020; 10(59): 4442-55. DOI: https://doi.org/10.36489/saudecoletiva.2020v10i59p4442-4455
33. Nora CRD, Beghetto MG. Patient safety challenges in primary health care: a scoping review. Rev Bras Enferm. 2020;73(5):e20190209. DOI: https://doi.org/10.1590/0034-7167-2019-0209
34. Pont J, Harding TW. Organisation and management of health care in prison. Council of Europe: Strasbourg [Internet]. 2019. [citado 15 nov. 2023]. Disponível em: https://rm.coe.int/guidelines-organisation-and-management-of-health-care-in-prisons/168093ae69
35. Epifania PS, Costa JSP, Freitas KS, Barros KCC, Maciel GS, Passos SSS. Experiência de estudantes de enfermagem durante a coleta de dados num presídio do semiárido baiano. Com. Ciências Saúde. 2021;32(4):21-7. DOI: https://doi.org/10.51723/ccs.v32i04.948
36. Joint Commission International. International Patient Safety Goals [Internet]. 2023. [citado 15 nov. 2023]. Disponível em: https://www.jointcommissioninternational.org/standards/international-patient-safety-goals/
37. International Pharmaceutical Federation. Patient safety. Pharmacists’ role in medication without harm. The Hague: International Pharmaceutical Federation (FIP) [Internet]. 2020 [citado 16 jan. 2024]. Disponível em: https://www.fip.org/file/4757
38. United Nations Development Programme. Objetivos de Desenvolvimento Sustentável [Internet]. 2024 [citado 16 jan. 2024]. Disponível em: https://www.undp.org/pt/brazil/objetivos-de-desenvolvimento-sustentavel
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Josemar Batista, Barbara Cristina Alberti, Eliane Miranda Rocha, Ivani Batista, João Kleber Nogueira, Kaynã Formigheri Ferreira
This work is licensed under a Creative Commons Attribution 4.0 International License.
By publishing in Revista Contexto & Saúde, authors agree to the following terms:
The works are licensed under the Creative Commons Atribuição 4.0 Internacional (CC BY 4.0) license, which allows:
Share — to copy and redistribute the material in any medium or format;
Adapt — to remix, transform, and build upon the material for any purpose, including commercial.
These permissions are irrevocable, provided that the following terms are respected:
Attribution — authors must be properly credited, with a link to the license and indication of any changes made.
No additional restrictions — no legal or technological measures may be applied that restrict the use permitted by the license.
Notes:
The license does not apply to elements in the public domain or covered by legal exceptions.
The license does not grant all rights necessary for specific uses (e.g., image rights, privacy, or moral rights).
The journal is not responsible for opinions expressed in the articles, which are the sole responsibility of the authors. The Editor, with the support of the Editorial Board, reserves the right to suggest or request modifications when necessary.
Only original scientific articles presenting research results of interest that have not been published or simultaneously submitted to another journal with the same objective will be accepted.
Mentions of trademarks or specific products are intended solely for identification purposes, without any promotional association by the authors or the journal.
License Agreement (for articles published from September 2025): Authors retain copyright over their article and grant Revista Contexto & Saúde the right of first publication.
