Root cause analysis of safety incidents in antineoplastic use in children.
Rev Bras Enferm
; 77Suppl 3(Suppl 3): e20230139, 2024.
Article
en En, Pt
| MEDLINE
| ID: mdl-39016429
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.
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Análisis de Causa Raíz
/
Errores de Medicación
/
Antineoplásicos
Límite:
Child
/
Humans
Idioma:
En
/
Pt
Revista:
Rev Bras Enferm
Año:
2024
Tipo del documento:
Article
País de afiliación:
Brasil
Pais de publicación:
Brasil