Proactive risk management of anti-infective administration process in an intensive care unit

Authors

DOI:

https://doi.org/10.51723/ccs.v34i03.1579

Keywords:

Healthcare Failure Mode and Effect Analysis, Anti-Infective Agents, Intensive Care Units, Safety Management, Patient Safety

Abstract

Introduction: The administration of anti-infectives must be managed with technologies and evidence in clinical practices and systems management. Objectives: To analyze proactive risk management in the process of administering anti-infectives in an Intensive Care Unit. Method: Qualitative study, in action research, with participant observation and focus group. The process was mapped, the risks were analyzed and the process was redesigned. Results: The process had 19 activities, two subprocesses, 16 failure modes and 23 causes. The failure modes were asepsis and dose error in the preparation of anti-infectives, and the causes were technical violations and memory lapses. Considerations relevant to Nursing: The study demonstrated the application of a risk management tool in the management of anti-infectives and raised knowledge gaps about the administration of anti-infectives. Conclusion: The administration's proactive risk management made it possible to identify risks, their causes and prioritize improvement actions.

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Author Biographies

Alaíde Francisca de Castro, Hospital Universitário de Brasília - HUB

Hospital Universitário de Brasília, Brasília, DF

Maria Cristina Soares Rodrigues, Universidade de Brasília - UnB

Universidade de Brasília. Faculdade de Ciências da Saúde. Departamento de Enfermagem. Campus Universitário Darcy Ribeiro, Brasília, DF

References

Associação Brasileira de Normas Técnicas. Catálogo ABNT NBR ISO 31000:2018. ABNT [Internet]. 2018 [acesso em 2020 jul 30]. Disponível em: https://www.abntcatalogo.com.br/norma.aspx?ID=392334

Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Portaria Nº 529, de 1º de abril de 2013 [Internet]. Institui o Programa Nacional de Segurança do Paciente. Brasília (DF): Ministério da Saúde; 2013 [acesso em 2020 jul 30]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html

World Health Organization. Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care. WHO [Internet] 2021 [cited 2022 Fev 27]. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan

National Coordinating Council for Medications Errors Reporting and Prevention. About Medication Errors. NCCMERP [Internet]; 2020 [cited 2020 Oct 30]. Available from: https://www.nccmerp.org/about-medication-errors

World Health Organization. The Conceptual Framework for the International Classification for Patient Safety (ICPS). WHO [Internet] 2010. [cited 2020 Oct 20]. Available from: https://www.who.int/patientsafety/implementation/taxonomy/ICPS-report/en/

Instituto para Práticas Seguras no Uso de Medicamentos Brasil. Programa Nacional de Segurança do Paciente: indicadores para avaliação da prescrição, do uso e da administração de medicamentos – parte II. ISSN:2317-2312 [Internet]. 2016. [acesso em 2022 mar 16]; 5(2). Disponível em: https://www.ismp-brasil.org/site/wp-content/uploads/2016/07/Boletim-ISMP-Brasil-Indicadores-II.pdf

World Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report 2021. WHO [Internet] 2021 [cited 2021 Jul 20]. Available from: https://www.who.int/publications/i/item/9789240027336

Brasil. Agência Nacional de Vigilância Sanitária. Plano de Contingência Nacional para Infecções causadas por Microrganismos Multirresistentes em Serviços de Saúde – PLACON-RM [Internet]. Brasília (DF): Anvisa; 2021 [acesso em 2020 fev 27]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/publicacoes/placon-nacional-mr-09-11-2021.pdf

Brasil. Ministério da Saúde. Programa Nacional de Segurança do Paciente – Anexo 03: Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasília (DF): Ministério da Saúde; 2013 [acesso em 2022 mar 16]. Disponível em: https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/protocolo-de-seguranca-na-prescricao-uso-e-administracao-de-medicamentos/

Souza RF, Alves AS, Alencar IG. de. Adverse events in the intensive care unit. J Nurs UFPE online [Internet]. 2018 [cited 2020 Jul 30]; 12(1):19-27. Available from: https://doi.org/10.5205/1981-8963-v12i1a25205p19-27-2018

Castro AF, Oliveira JP, Rodrigues MC. Anti-infective medication administration errors by dose omission. Acta Paul Enferm [Internet]. 2019 [cited 2020 Jul 30]; 32(6):667-73. Available from: https://doi.org/10.1590/1982-0194201900092

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using Health Care Failure Mode and Effect Analysis: The VA National Center for Patient Safety’s Prospective Risk Analysis System. Jt Comm J Qual Improv [Internet]. 2002 [cited 2020 Oct 20]; 28(5):248-67. Available from:10.1016/s1070-3241(02)28025-

Anjalee JAL, Rutter V, Samaranayake NR. Application of failure mode and effect analysis (FMEA) to improve medication safety: a systematic review. Postgrad Med J [Internet]. 2021 [cited 2022 Fev 20]; 97:168-74. Available from:10.1136/postgradmedj-2019-137484

Bizagi Modeler. Software de mapeamento. Versão. 3.7.0.123. 2020.

Abi AXCF, Cruz EDA, Pontes L, Santos T, Felix JVC. The Healthcare Failure Mode and Effect Analysis as a tool to evaluate care protocols. Rev Bras Enferm [Internet]. 2022 [cited 2023 Fev 20];75(3):e20210153. Available from: https://doi.org/10.1590/0034-7167-2021-0153

Belarmino GM, Renovato RD. Matriz de competências relacionadas aos medicamentos para o enfermeiro em unidade de terapia intensiva. Rev Enferm UFSM [Internet]. 2020 [cited 2023 Fev 20]; 10(e99):1-17. Available from: https://doi.org/10.5902/2179769247447

Berdot S, Roudot M, Schramm C, Katshian S, Duriex P, Sabatier B. Interventions to reduce nurses’ medication administration errors in inpatient settings: a systematic review and meta-analysis. Int J Nurs Stud [Internet]. 2016 [cited 2023 Fev 20]; 53:342-35. Available from: https://doi.org/10.1016/j.ijnurstu.2015.08.012

Reason J. Human error: models and management. BMJ (Clinical research ed.) [Internet]. 2000 [cited 2020 Oct 20]; 320(7237):768-70. Available from: doi.org/10.1136/bmj.320.7237.768

Instituto para Práticas Seguras no Uso de Medicamentos Brasil. Prevenção de erros relacionados às interrupções dos profissionais durante o processo de medicação. Boletim ISMP Brasil [Internet]. 2019 [acesso em 2020 oct 30]. Disponível em: https://www.ismp-brasil.org/site/wp-content/uploads/2019/06/BOLETIM-ISMP-BRASIL-INTERRUPCOES-JUN-19.pdf

Costa PCA, Nunes VMA, Pimenta IDSF, Bezerra TS1, Piuvezam G, Gama ZAS. Failure mode and effect analysis in the preparation and dispensation of chemotherapy. Enfermería Glob [Internet]. 2020 [cited 2022 Fev 20]; 58(1): 96-108. Available from: https://doi.org/10.6018/eglobal.389551

Vida MAC, Plata JEM, Morales-Molina JA, Lázaro JJP, Robles PA. Identification and prioritisation of risks in a hospital pharmacy using healthcare failure mode and effect analysis. Eur J Hosp Pharm [Internet]. 2019 [cited 2022 Fev 20]; 26:66-72. Available from:10.1136/ejhpharm-2017-001242

Farzi S, Irajpour A, Saghaei M, Ravaghi H. Causes of medication errors in intensive care units from the perspective of healthcare professionals. J Res Pharm Pract [serial online] [Internet]. 2017 [cited 2022 Fev 20]; 6:158-65. Available from: https://www.jrpp.net/text.asp?2017/6/3/158/215238

Atienza-Martín F, et al. El método AMFE (Análisis Modal de Fallos y Efectos) aplicado a la anticoagulación de pacientes con fibrilación auricular no valvular. SEMERGEN [Internet]. 2019 [cited 2022 Fev 20]; 45(3): 169-79. Available from: https://doi.org/10.1016/j.semerg.2018.04.011

Instituto para Práticas Seguras no Uso de Medicamentos Brasil. Prevenção de Erros por Omissão. [Internet]. Boletim ISMP Brasil [Internet]. 2019 [acesso em 2022 mar 16]. ISSN: 2317-2312; 8(5). Disponível em: https://www.ismp-brasil.org/site/wp-content/uploads/2019/08/BOLETIM-ISMP-JULHO_PREVENCAO-DE-ERROS-DE-OMISSAO-DE-MEDICAMENTOS.pdf

Instituto para Práticas Seguras no Uso de Medicamentos Brasil. Anti-infecciosos: erros de medicação, riscos e práticas seguras na sua utilização. Boletim ISMP Brasil [Internet]. 2019 ISSN: 2317-2312 [acesso em 2020 oct 30]; 8(7). Disponível em: https://www.ismp-brasil.org/site/wp-content/uploads/2019/10/BOLETIM-ISMP_SETEMBRO_2019_anti-infecciosos.pdf

Paparella S F. Taking another look at independent double checks. J Emerg Nurs [Internet]. 2013 [cited 2022 Fev 20]; 39:631-2. Available from: https://doi.org/10.1016/j.jen.2013.08.013

Barbagelata EU. Implementación de estratégias de prevencíon de errores em el processo de administración de medicamentos: um enfoque para enfermeira em cuidados intensivos. Rev Méd Clín Condes [Internet]. 2016 [cited 2022 Fev 20]; 27(5):594-604. Available from: https://doi.org/10.1016/j.rmclc.2016.09.005

Published

2024-04-23

How to Cite

1.
de Castro AF, Soares Rodrigues MC. Proactive risk management of anti-infective administration process in an intensive care unit. Com. Ciências Saúde [Internet]. 2024 Apr. 23 [cited 2024 May 19];34(03). Available from: https://revistaccs.escs.edu.br/index.php/comunicacaoemcienciasdasaude/article/view/1579

Issue

Section

18º Prêmio CEPEn 2023