Please use this identifier to cite or link to this item: http://repositorio.unicamp.br/jspui/handle/REPOSIP/321760
Type: TESE DIGITAL
Title: Análise de causa raiz combinada com técnicas de engenharia de fatores humanos para a investigação de eventos adversos em estabelecimentos assistenciais de saúde : Root cause analysis combined with human factors engineering tools for adverse events investigation in healthcare
Title Alternative: Root cause analysis combined with human factors engineering tools for adverse events investigation in healthcare
Author: Batista, Victor Hugo Tsukahara, 1986-
Advisor: Calil, Saide Jorge, 1950-
Abstract: Resumo: A questão de segurança do paciente é um assunto que tem sido discutido nos dias de hoje, muito por conta de importantes publicações que demonstraram a atualidade e pertinência do tema na área da saúde. Para a promoção da segurança do paciente, uma das alternativas existentes para se atingir este objetivo é a investigação de eventos adversos, que permitem o entendimento de erros recorrentes, além de condições nos estabelecimentos assistenciais de saúde (EAS) que podem provocá-los. Existem várias metodologias que podem ser aplicadas para este propósito, como Health Failure Mode and Effect Analysis, Rasmussen, entre outras. Contudo, uma das mais utili-zadas para investigação de eventos adversos é a Análise de Causa Raiz (RCA). No entanto, uma das limitações desta técnica é que ela indica o que deve ser feito durante a investigação, mas não indica claramente como se chegar aos resultados. Outra questão também se relaciona com o foco dado na análise do evento adverso, que geralmente possui um direcionamento em se analisar polí-ticas e falhas dos indivíduos, sem utilizar uma visão mais ampla de análise. Uma alternativa para solucionar estas limitações é a Engenharia de Fatores Humanos (HFE), com seu conjunto de téc-nicas que podem complementar a metodologia RCA, podendo auxiliar na busca por respostas aos questionamentos que são desenvolvidos, além de ampliar a perspectiva de análise do evento ad-verso, por meio da visão sócio-técnica adotada para a análise do Estabelecimento Assistencial de Saúde. Portanto, esta dissertação de mestrado apresenta uma nova metodologia que utiliza a es-trutura de investigação da Análise de Causa Raiz e a combina com as técnicas de Engenharia de Fatores Humanos, para a análise de eventos adversos em EAS. A dissertação também apresenta os resultados de sua validação em um estudo de caso, em que foi demonstrado que o método po-de ser considerado como uma alternativa viável para a análise de intercorrências

Abstract: An important way to promote patient safety is through the investigation of adverse events (AEs), which allows the understanding of common errors and the conditions of the occur-rence and causes. There are many available methods used in the health area to carry on an investigation, such as: Health Failure Mode and Effect Analysis (HFMEA), Rasmussen Framework, Human Factor Engineering and so on. Among those many methods, one of the most used within the healthcare area is the Root Cause Analysis (RCA). Though extremely useful, it presents some limitations, such as: indication of what must be done during adverse event investigation but lacks clarity to indicate how to develop the indicated activities. Anoth-er issue regards the investigation focus: it is usually geared toward policy violations and staff failures, ignoring a broader analysis. A solution to mitigate RCA limitations may be through the combination of tools available in a different method, this could facilitate the search for answers from questions already developed when using RCA, as well as broaden the perspec-tive adopted to investigate the adverse event. This study presents a methodology, that com-bines a set of tools, derived from two methods: RCA and HFE. The methodology starts with informal interviews, usually with local staff that working at the hospital where adverse event had happened to understand what happened. Find out if any medical equipment was involved and discover points that need further investigation. A literature review is then carried out to expand the understanding of the adverse event, looking for similar occurrences that happened in other healthcare units. This review also includes the investigation of policies and regula-tions that may be related to the specific adverse event as well as medical device features, op-erating principles and recalls. Following the reviews, it is necessary to understand proce-dures, activities and the equipment interface (if there is a device involved in AE). Shadowing and Task Analysis, tools of Human Factors Engineering, are applied to understand the pro-cedure and activities related to the adverse event, looking for critical issues that may repre-sent active failures or latent conditions for its occurrence. Heuristic Analysis is then applied to understand medical device interface, identifying usability problems that may contribute to the AE. Based on all the information acquired and the identification of what requires addi-tional clarification, a specific set of questions is developed. This is applied to all healthcare professionals that work at the hospital service unit where the adverse event occurred (acci-dent scenario). The set of collected data is then analyzed and used to support and identify the latent conditions and active failures related to the adverse event. This study presents the re-sults of the methodology application in a real case study involving an adverse event caused by a mechanic ventilator. The outcome of the study showed that the combination of HFE tools to RCA could augment the investigation scope, mainly when dealing with adverse events caused by the equipment interface
Subject: Engenharia biomédica
Segurança do paciente
Avaliação de riscos
Editor: [s.n.]
Date Issue: 2016
Appears in Collections:FEEC - Dissertação e Tese

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