Tools to organize the work process in patient safety
Herramientas para organizar el proceso de trabajo en seguridad del paciente
Ferramentas para a organização do processo de trabalho na segurança do paciente
Marielli Trevisan Jost; Aline Branco; Bárbara Rodrigues Araujo; Karin Viegas; Rita Catalina Aquino Caregnato
Abstract
Objective: to discuss the use of Failure Mode and Effects Analysis tools and their application in health care.
Method: this is a reflection article, aiming at presenting the proper application format for both tools, followed by their differences in execution in the work processes.
Results: both models have the same purpose, being directed to the detection of failures even before their manifestation, directly assisting in the promotion of safety. The analysis of the error with the participation of the teams and the generation of failure rates has repercussions on the planning and implementation of practical actions aimed at patient safety.
Conclusion and implications for the practice: although similar, there are distinctions regarding the prioritization of failures to list practical corrective actions, mainly in the calculation of the Risk Priority Index related to severity, probability of occurrence and failure detection. Both tools are shown to be important allies to health managers for the detection of serious failures that put care free from adverse events at risk.
Keywords
Resumen
Palabras clave
Resumo
Objetivo: discutir acerca da utilização das ferramentas de Análise de Modo e Efeitos de Falha e sua aplicação na assistência à saúde.
Método: trata-se de um artigo de reflexão visando à apresentação do formato próprio de aplicação de ambas as ferramentas seguida das suas diferenças de execução nos processos de trabalho.
Resultados: ambos os modelos possuem a mesma finalidade, sendo direcionados para a detecção de falhas antes mesmo da sua manifestação, auxiliando diretamente na promoção da segurança. A análise do erro, com a participação das equipes e a geração de índices de falhas, repercute no planejamento e na implementação de ações práticas voltadas à segurança do paciente.
Conclusão e implicações para a prática: embora semelhantes, existem, entre eles, distinções quanto à priorização das falhas para elencar ações práticas corretivas, principalmente no cálculo do Índice de Prioridade de Risco relacionado à gravidade, na probabilidade de ocorrência e na detecção das falhas. Ambas as ferramentas se mostram como importantes aliadas dos gestores de saúde para a detecção de falhas graves que colocam em risco a assistência livre de eventos adversos.
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Referencias
1 Lee SH, Phan PH, Dorman T, Weaver SJ, Pronovost PJ. Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMC Health Serv Res. 2016;16(1):254.
2 National Patient Safety Foundation. Free from harm: accelerating patient safety improvement fifteen years after to err is human [Internet]. Boston: NPSF; 2015 [citado 26 maio 2020]. Disponível em:
3 Farup PG. Are measurements of patient safety culture and adverse events valid and reliable? Results from a cross sectional study. BMC Health Serv Res. 2015;15(1):186.
4 Sorra J, Gray L, Streagle S, Famarolo T, Yount N, Behm J. AHRQ hospital survey on patient safety culture: user’s guide [Internet]. Rockville: Agency for Healthcare Research and Quality; 2016. (AHRQ Publication; no. 15(16)-0049-EF) [citado 26 maio 2020]. Disponível em:
5 Brandão MGSA, Brito OD, Barros LM. Risk management and patient safety: mapping the risk of adverse events in the emergency of a teaching hospital. Rev Adm Saúde [Internet]. 2018; [citado 2020 out 24];18(70):1-13. Disponível em:
6 Joint Commission International. International patient safety goals [Internet]. Oak Brook: Joint Commission International; 2020 [citado 20 maio 2020]. Disponível em:
7 Galdino SV, Reis EMB, Santos CB, Soares FP, Lima FS, Caldas JG et al. Quality tools in management of health services: literature review integrative. Rev Elet Gest Saúde [Internet]. 2016; [citado 2020 out 24];7(1):1023-57. Disponível em:
8 Shah A, Course S. Building the business case for quality improvement: a framework for evaluating return on investment. Future Healthc J. 2018;5(2):132-7.
9 Siman AG, Brito MJM. Changes in nursing practice to improve patient safety. Rev Gaúcha Enferm. 2016;37(spe):1-9. PMid:28489153.
10 Matos DAR, Silva SOP, Lima CR. Nursing of work: addressing competencies and skills for the nurses’ performance. Temas em Saúde [Internet]. 2017; [citado 2020 out 24];17(3):204-2016. Disponível em:
11 Carvalho IM, Ferreira DKS, Nelson ARC, Duarte FHS, Prado NCC, Silva RAR. Systematization of nursing care in mediate post-operative of cardiac surgery. Rev Pesqui. 2016;8(4):5062-7.
12 Stamatis DH. The ASQ Pocket Guide to Failure Mode and Effect Analysis (FMEA). Milwaukee: ASQ Quality Press; 2015.
13 Moraes CD, Rabin EG, Viegas K. Assessment of the care process with orthotics, prosthetics and special materials. Rev Bras Enferm. 2018;71(3):1099-105.
14 Biazoto B, Tokarski M. Comparação entre métodos de priorização de riscos em radioterapia. Rev Bras Física Médica. 2016;10(1):17-21.
15 Sorrentino P. Use of failure mode and effects analysis to improve Emergency Department Handoff Processes. Clin Nurse Spec. 2016;30(1):28-37.
16 Hinrichsen SL, Brayner KAC, Paixão SLL, Vilella TAS, Lemos MC, Silva ED. Perception of the nursing team about causes of near miss in the medicament delay using Failure Mode and Effects Analysis – FMEA. Rev Adm Saúde [Internet]. 2017; [citado 2020 out 24];17(66):1-18. Disponível em:
17 Moraes CS, Rabin EG, Viégas K. Assessment of the care process with orthotics, prosthetics and special materials. Rev Bras Enferm. 2018;71(3):1099-105.
18 Jost MT, Branco A, Viegas K, Caregnato RCA. Systematization of perioperatory nursing assistance: evaluating work processes in the transoperatory. Enferm Foco [Internet]. 2019; [citado 2020 out 24];10(7):43-9. Disponível em:
19 Paranhos MM, Bachega SJ, Tavares DM, Calife NFS. Aplicação da análise de modo e efeitos de falha para o gerenciamento de riscos de um projeto. Rev S&G [Internet]. 2017; [citado 2020 out 24];11(2016):444-54. Disponível em:
20 Institute for Healthcare Improvement. QI essentials Toolkit: Failure Modes and Effects Analysis (FMEA) IHI Toolkit [Internet]. Boston: IHI; 2017 [citado 2020 maio 26]. Disponível em:
21 Ofek F, Magnezi R, Kurzweil Y, Gazit I, Berkovitch S, Tal O. Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards. Isr J Health Policy Res. 2016;5(30):30.
22 Bhattacharjee P, Dey V, Mandal UK. Risk assessment by failure mode and effects analysis (FMEA) using an interval number based logistic regression model. Saf Sci. 2020;132:1-10.
23 Joint Commission Resources, Joint Commission International. Failure mode and effects analysis in health care: proactive risk reduction [Internet]. 3rd ed. Illinois: JCR; 2010 [citado 2020 maio 26]. Disponível em:
24 Rah JE, Manger RP, Yock AD, Kim GY. A comparison of two prospective risk analysis methods: Traditional FMEA and a modified healthcare FMEA. Med Phys. 2016;43(12):6347-53.
25 Goodrum L, Varkey P. Prevention is better: the case of the underutilized failure mode effect analysis in patient safety. Isr J Health Policy Res. 2017;6(10):10.
26 Chuang S, Liu D, Wang C, Lee T. Application deficiencies of proactive analysis method for health care risk management. J Healthc Qual [Internet]. 2020; [citado 2020 out 24];14(2):34-41. Disponível em:
27 Liu H, Zhang L, Ping Y, Wang L. Failure mode and effects analysis for proactive healthcare risk evaluation: a systematic literature review. J Eval Clin Pract. 2020;26(4):1320-37.
28 Dehnavieh R, Ebrahimipour H, Molavi-Taleghani Y, Vafaee-Najar A, Noori Hekmat S, Esmailzdeh H. Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode and Effects Analysis (HFMEA). Glob J Health Sci. 2014;7(1):322-31. PMid:25560332.
Submitted date:
06/06/2020
Accepted date:
27/11/2020
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