Root cause analysis of safety incidents in antineoplastic use in children.

IF 1.2 Q3 NURSING

Revista Brasileira De Enfermagem Pub Date : 2024-07-15 eCollection Date: 2024-01-01 DOI:10.1590/0034-7167-2021-0139

Elizangela Domiciano Garcia Barreto, Valcieny Souza Sandes, Gustavo Cattelan Nobre, Monica Martins, Sima Esther Ferman, Elisangela Costa Lima

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引用次数: 0

Abstract

Objectives: to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients.

Methods: a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors.

Results: in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages.

Conclusions: the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

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儿童抗肿瘤药物使用安全事故的根本原因分析。

目的：确定并分析导致儿科肿瘤患者抗肿瘤药物处方、制备和分配过程中发生安全事故的因素。方法：一项质量改进研究，重点关注肿瘤儿科药物护理过程，确定并分析2019-2020年间发生的事故。一个多学科小组进行了根本原因分析（RCA），确定了主要诱因。结果：2019 年，记录了 7 起事故，其中 57% 与处方有关。2020 年，通过主动搜索，发现了 34 起事故，其中 65% 与处方有关，29% 与制剂有关，6% 与配药有关。主要诱因是中断、缺乏电子警报、工作负荷过重、培训和人员短缺。结论：结果表明，对已发现的事件进行充分记录和应用 RCA 可以提高儿科肿瘤护理质量，绘制诱因图，并使管理人员能够制定有效的行动计划，以降低与该流程相关的风险。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Revista Brasileira De Enfermagem NURSING-

CiteScore

2.30

自引率

7.70%

发文量

477

审稿时长

21 weeks

期刊介绍： The Revista Brasileira de Enfermagem created in 1932, March 20 is the official publication of the Associação Brasileira de Enfermagem (Brazilian Nursing Association) has as purpose to disseminate the scientific production from different nursing interest areas of knowledge, including those which express the political project of the Association. The Revista Brasileira de Enfermagem is the oldest journal of the Brazilian nursing. Its first title was "Annaes de Enfermagem" from 1932 to 1941, being entitled Anais de Enfermagem" until 1955, when its title was changed to the current.