Banca de DEFESA: MABEL MENDES CAVALCANTI

Uma banca de DEFESA de MESTRADO foi cadastrada pelo programa.
DISCENTE : MABEL MENDES CAVALCANTI
DATA : 14/10/2016
HORA: 15:30
LOCAL: DEPARTAMENTO DE SAÚDE COLETIVA
TÍTULO:

Perspective Risk Management Applied To Medicine Dispensing Errors In A Brazilian Hospital.


PALAVRAS-CHAVES:

safety patient; quality of health care; errors medication; risk management. 


PÁGINAS: 30
GRANDE ÁREA: Ciências da Saúde
ÁREA: Saúde Coletiva
SUBÁREA: Saúde Pública
RESUMO:

Introduction: health services have increasing use of complex technologies and processes that provide high risks for patient care. Prospective methods of identification and risk reduction can be helpful, but there is little description of your application in the Brazilian context. Objective: this study aims to describe the application of HFMEA tool in drug dispensing process, in order to prospectively know the possible failures and their effects. Method: it is a descriptive study, developed in a university hospital, using the HFMEA according to Veterans Affairs, implemented by multidisciplinary team for 3 months. They were identified and analyzed failure modes in the drug dispensing process, according to their severity and frequency, from the priority analysis of causes, management and monitoring of risks. Results: the highlights 21 ways to fail in dispensing drugs. Subprocesses with major failures were, in descending order, separation of the product (06), prepare the dose (06), evaluation of the prescription (03), unitarization of drugs and delivery of the dose (02), the drug release (01) and conference dose (01). Three of these failures were selected for analysis and intervention: "misidentification of medicine" (unitarization), "different separate drug's prescribed" (separation of the product) and "delay in dose delivery" (the drug release). After the analysis of the causes, we established some necessary interventions, namely: audit to assess adherence to the sub-process protocol "unitarization" and dissemination of results, construction of a standard operating protocol for storing medicines with sound and the like spelling and implementation of the security protocol in prescription, use and administration of medications. Conclusion: the study allowed us to analyze the process of dispensing drugs, where we identified the possible failures that could increase the risk of adverse events in this stage of the medication process. HFMEA was useful to assist multidisciplinary group better understand the weaknesses in the work process, which can help to faults, and assists in prioritizing corrective interventions and possible improvements to safety in dispensing drugs.


MEMBROS DA BANCA:
Presidente - 1868020 - ZENEWTON ANDRE DA SILVA GAMA
Interno - 2495705 - GRASIELA PIUVEZAM
Externo à Instituição - HELAINE CARNEIRO CAPUCHO - EBSERH
Notícia cadastrada em: 13/10/2016 10:54
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