Segurança do paciente da administração de medicamentos na atenção primária à saúde: estudo de aplicação da failure mode and effects analysis e proposta de guia de boas práticas para profissionaid de saúde

Abstract

Introduction: This Master’s Thesis, part of the research line on Adult and Elderly Health Quality, addresses issues that arise from care practices in Basic Health Units (UBS) in the Federal District. Since 2013, Brazil has implemented a National Patient Safety Policy aimed at improving care processes in hospital settings. However, significant knowledge gaps remain in Primary Health Care that hinder the necessary changes and continuous improvement in the work processes of health professionals at Basic Health Units. Objective: The primary aim of this study is to identify and analyze the main failure modes within the work process of the medication room. Specific objectives: 1. Map the steps involved in the nursing team's work process during medication administration, including the roles of nurses, physicians, dentists, and pharmacists in Primary Health Care. 2. Identify potential risks of failure in the work process and their contributing factors. 3. Develop a guide for primary health care professionals that focuses on patient safety, particularly safe medication administration. Method: A study utilizing the Failure Mode and Effects Analysis (FMEA) methodology was conducted. This methodology helps identify potential failures in a system, design, or process, aiming to minimize or eliminate risks before failures occur. Eleven health professionals took part in the research, including nurses, physicians, pharmacists, dentists, and nursing technicians, all of whom are directly or indirectly involved in the prescription or administration of medications at two Basic Health Units in the Southwest Health Region of the Federal District. The study was conducted in three stages: 1. Mapping the work process in the medication room using semi-structured interviews. 2. Applying the FMEA methodology to identify failures, their effects, causes, and control measures. 3. Discussing failure modes, causes, and consequences in a focus group, along with strategies for mitigating failures related to medication administration in the Basic Health Unit. Results: The study identified both unacceptable and acceptable failure modes within the work process, including patient reception in the medication room, medication preparation, medication administration, recording information after administration, and post-administration observation. The focus group validated these failure modes, discussed their impacts, and proposed strategies to minimize harm. Conclusion: The identified failure modes pertain to the care process in the medication room of primary health care. They are primarily the result of working conditions, human behavior, management challenges, and care culture. Proposed mitigation strategies include training, revising workflows and routines, adhering to established protocols, and improving the work environment. Products: A Best Practices Guide on patient safety was developed, which serves to guide health professionals involved in patient care in the medication administration rooms of Basic Health Units.