Banca de QUALIFICAÇÃO: Márcia Amaral Dal Sasso

Uma banca de QUALIFICAÇÃO de DOUTORADO foi cadastrada pelo programa.
STUDENT : Márcia Amaral Dal Sasso
DATE: 04/12/2024
TIME: 14:00
LOCAL: Plataforma Teams
TITLE:

“Patient Safety Incident Response in the Brazilian Unified Health System: Proposal for a Model with Proportional and Evidence-Based Actions.” 

KEY WORDS:

“Risk Management; Systems Analysis; Patient Safety; Total Quality Management; Quality Improvement; Health Systems, Outcome and Process Assessment; Health Care; Near Miss, Healthcare.

PAGES: 100
BIG AREA: Ciências da Saúde
AREA: Farmácia
SUMMARY:

“The importance of incident analysis is recognized across complex services, which allocate considerable resources for this purpose, including periodic reviews of the applied analysis methods. However, healthcare services have retained their incident analysis models for years, with limited evidence of improvements achieved. The patient safety incident analysis cycle includes incident identification, information collection, incident analysis, corrective action development, implementation and monitoring, followed by evaluation and learning. A well-executed approach to the information collection and analysis phases is essential, as the data gathered allows for the recognition of contributing factors, enabling the proposal of actions to mitigate risks and reduce the likelihood of event recurrence. In Brazil, the discussion of this topic gained momentum and visibility with the institution of the National Patient Safety Program. Since then, the significance of identifying incidents in healthcare services has been intensely debated by healthcare professionals and researchers, and while incident analysis is acknowledged as a crucial step, many healthcare institutions still conduct superficial information collection, resulting in standardized actions with limited impact on the identified issues. Given this context, this study aims to analyze voluntary reports submitted by professionals via an application developed by a Brazilian public company responsible for managing 40 public university hospitals and propose a new incident response framework for patient safety applicable to the Brazilian Unified Health System (SUS). This epidemiological study is a cross-sectional, retrospective, observational, and mixed-method analysis, designed to examine various types of incidents reported by notifiers, followed by a rapid systematic review to identify efficient and effective incident analysis methods and models, and a document analysis of official publications on incident response from two countries with universal healthcare systems. This process culminates in the development of a patient safety incident response framework for the SUS, using a hypothesis analysis model based on expert opinions and employing the Delphi method. The validation of the proposed framework will be conducted through its application to specific incidents identified in the study hospitals to assess its practical adequacy. At this stage, different factors have been observed for each type of patient safety incident. Additionally, it was found that risk assessment efforts to outline preventive actions had limited impact on incident occurrence. The root cause analysis method, once widely recommended, has been found to have limitations and is no longer broadly endorsed for incident analysis. Furthermore, a European country with a universal healthcare system recently overhauled its incident response framework following various reports indicating that core analyses of highly significant incidents did not yield the advancements in patient safety anticipated. These preliminary findings underscore the need for a new patient safety incident response framework that can yield improved analysis outcomes within the SUS_” 

COMMITTEE MEMBERS:
Externa à Instituição - SUSANA CECAGNO - EBSERH
Externa à Instituição - GRASIELA PIUVEZAM - UFRN
Presidente - 1055549 - HELAINE CARNEIRO CAPUCHO
Externa ao Programa - 2205302 - THATIANNY TANFERRI DE BRITO PARANAGUA - null