Risk management proposal: flow mapping, risk and safety strategies in a surgical center

Authors

DOI:

https://doi.org/10.33448/rsd-v11i6.22283

Keywords:

Health Management; Patient Safety; Quality of Health Care; Nursing; Surgicenters.

Abstract

Objectives: To Map and describe the activities and risks of a surgical process in a specialized hospital, and propose strategies for patient safety through a risk management proposal. Methodology: Qualitative research, in the form of action research, carried out with 12 professionals working in a surgical center of a specialized hospital in northwestern São Paulo, from May to June 2017. Brainstorming tools were used to understand the internal flow, Business Process Model and Notation and Supplier, Input, Process, Output and Customer for process mapping, National Health Agency's Risk Matrix for risk stratification and improvement proposals, the methodology proposed by the Institute of Healthcare Improvement. Results: In the mapping, the operating room was divided into admission; operating room and anesthetic recovery, which resulted in 13 processes and 42 activities described. It was possible to observe relevant interactions with administrative and support processes. 42 risk situations were identified; 31.8% were classified as medium risk, 43.1% high and 25.0% extreme, which generated 87 proposals for interventions to improve patient safety. Conclusion: Mapping the activities and risks of surgical processes provides the manager with tools for decision making; above all, the adoption of corrective strategies for each of the risk points in the flow of patient care.

References

Araújo, I. S., & Carvalho, R. (2018). Eventos adversos graves em pacientes cirúrgicos: ocorrência e desfecho. Rev SOBECC, 23(2), 77-83.

Baldissera, A. Pesquisa-ação: uma metodologia do “conhecer” e do “agir” coletivo (2001). Sociedade em Debate, 7(2), 5-25.

Brasil (2017). Gestão de riscos e investigação de Eventos Adversos relacionados à assistência à saúde. Anvisa, 94p.

Chaves, L. D. P., Mininel, V. A., Silva, J. A. M., Alves, L. R., Silva, M. F., & Camelo, S. H. H. (2017). Nursing supervision for care comprehensiveness. Revista Brasileira de Enfermagem, 70(5), 1106-1111.

Cordeiro, L., & Soares, C. B. (2018). Action research in the healthcare field: a scoping review. JBI Database of Systematic Reviews and Implementation Reports, 16(4), 1003-1047.

Degirolamo, K, D'Souza, K, Hall, W, Joos, E, Garraway, N, Sing, C. K., & Hameed, M. (2018). Process mapping as a framework for performance improvement in emergency general surgery. Canadian Journal of Surgery, 61(1), 13-18.

Florêncio, A. C. U. S., Carvalho, R., & Barbosa, G. S. (2011). O impacto do trabalho do centro de materiais na qualidade da assistência. Revista SOBECC, 16(1), 31-39.

Fragata, J, Sousa, P & Santos, R. S. (2014). Organizações de saúde seguras e fiáveis/confiáveis. In: Sousa, P & Mendes, W (Eds.). Segurança do paciente: criando organizações de saúde seguras (2nd ed., pp.17-36). CDEAD, ENSP, FIOCRUZ.

Gutierres, L. S., Santos, J. L. G., Barbosa, S. F. F., Maia, A. R. C., Koerich, C., & Gonçalves, N. (2019). Adherence to the objectives of the Safe Surgery Saves Lives Initiative: perspective of nurses. Revista Latino-Americana de Enfermagem, 27, e3108.

Institute for Healthcare Improvement. (2021). Science of Improvement. http://www.ihi.org/about/Pages/ScienceofImprovement.aspx

Kitney, P, Tam, R, Bennett, P, Buttigieg, D, Bramley, D & Wang, W (2016). Handover between anaesthetists and post-anaesthetic care unit nursing staff using ISBAR principles: A quality improvement study. Journal of Perioperative Nursing, 29(1), 30-35.

Marquis, B. L., & Huston, C. J. (2015). Administração e Liderança em Enfermagem: Teoria e Prática (8th ed.). Artmed.

National Academies of Sciences, Engineering, and Medicine (NASEM) (2018). Crossing the Global Quality Chasm: Improving Health Care Worldwide. The National Academies Press.

Organização Mundial da Saúde (2009). Segundo desafio global para a segurança do paciente: Cirurgias seguras salvam vidas (orientações para cirurgia segura da OMS). http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_salvam_vidas.pdf.

Organização Nacional de Acreditação (2018). Manual Brasileiro de Acreditação – Organizações Prestadoras de Serviços de Saúde.

Pena, M. M., & Melleiro, M. M. (2018). Eventos adversos decorrentes de falhas de comunicação: reflexões sobre um modelo para transição do cuidado. Revista de Enfermagem da UFSM, 8(3), 616-625.

Sales, C. B., Bernardes, A., Gabriel, C. S., Brito, M. F. P., Moura, A. A., & Zanetti, A. C. B. (2018). Standard Operational Protocols in professional nursing practice: use, weaknesses and potentialities. Revista Brasileira de Enfermagem, 71(1), 126-134.

Sanchis, D. Z., Haddad, M. C. F. L., Giotto, E., & Silva, A. M. R. (2020). Patient safety culture: perception of nursing professionals in high complexity institutions. Revista Brasileira de Enfermagem, 73(5), e20190174.

Santos, A, Pierobon, N, Zarichen, F. A., et al. (2021). Eventos Adversos em pacientes cirúrgicos: Revisão integrativa. Research, Society and Development, 10(4), e16810413896.

Silva, F. G., Junior, N. J. O., Oliveira, D. O., Nicoletti, D. R., & Comin, E. (2015). Analysis of adverse events in an outpatient surgical center. Revista SOBECC, 20(4), 202-209.

Silva, L. C. (2015). Gestão e melhoria de processos: conceitos, práticas e ferramentas (pp. 78-82). Brasport.

Tomé, M. F., & Lima, A. F. C. (2015). Mapping the process of reprocessing cotton drapes. Revista SOBECC, 20(4), 197-201.

Tostes, M. F. P. & Galvão, C. M. (2019). Surgical safety checklist: benefits, facilitators, and barriers in the nurses’ perspective. Revista Gaúcha de Enfermagem, 40 (Special Issue), e20180180.

Vilela, R. P. B., & Jericó, M. C. (2020). Validation of the drug chain flowchart as a preventive technology for medication errors. Mundo da Saúde, 44, 325-337.

Vituri, D. W., & Évora, Y. D. M. (2015). Total Quality Management and hospital nursing: an integrative literature review. Revista Brasileira de Enfermagem, 68(5), 945-952.

World Health Organization (2009). Conceptual Framework for the International Classification for Patient Safety: final technical report. https://www.who.int/patientsafety/taxonomy/icps_full_report.pdf

Published

29/04/2022

How to Cite

FACHOLA, K. .; VILELA, R. P. B.; CALIL, A. S. G. .; FELDMAN, L. B. .; NOGUEIRA, D. N. G.; SILVA, C. P. R. .; TRUZZI, I. G. de C. .; BANHOS, N. S. .; RUIZ, P. B. de O. .; RODRIGUEZ, E. O. L. .; LAUTENSCHLAEGER, D. C. de O. .; JERICÓ, M. de C. . Risk management proposal: flow mapping, risk and safety strategies in a surgical center. Research, Society and Development, [S. l.], v. 11, n. 6, p. e33111622283, 2022. DOI: 10.33448/rsd-v11i6.22283. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/22283. Acesso em: 22 nov. 2024.

Issue

Section

Health Sciences