Aplicação da ferramenta bow-tie como recurso de disseminação da política de segurança do paciente
Arquivos
Data
2017
Autores
Costa, Daniela Akemi 
Orientadores
Bohomol, Elena
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Analisar a aplicabilidade da ferramenta Bow-Tie como recurso de disseminação da política de segurança do paciente. Método: Foi realizado um estudo descritivo e exploratório de abordagem quantitativa, em um hospital privado no município de São Paulo, estruturado em duas etapas, sendo a primeira uma análise documental de Bow-Ties construídas por grupos multiprofissionais durante oficinas planejadas de abril a julho de 2014 nos turnos manhã, tarde e noite; e a segunda etapa uma análise estatística comparativa e correlacional utilizando testes de Kruskal Wallis, Mann-Whitney e Spearman para conhecer a opinião dos profissionais por meio de uma pesquisa estruturada com seis afirmativas e cinco opções de resposta utilizando escala de Likert (concordo totalmente, concordo, nem concordo nem discordo, discordo, discordo totalmente), com cálculo amostral de 95% de intervalo de confiança e 5% de margem de erro de uma população de profissionais de assistência direta ao paciente e que participaram das oficinas de construção das Bow-Ties. Resultados: foram realizadas 19 oficinas com participação de 505 colaboradores, sendo 254 assistenciais. Foram construídas 123 Bow-Ties com 70 temas diferentes (47 assistenciais), sendo os dois mais prevalentes: Erros de Medicação e Queda de Pacientes. Foram identificados, respectivamente aos dois temas, 29 e 22 perigos; 95 e 81 barreiras; 19 e 12 consequências; e 68 e 53 ações de mitigação. A relação barreira e perigo foi de 3,28 e 3,68; e a relação de ações de mitigação e consequências de 3,58 e 4,42. A opinião dos profissionais quanto a aplicabilidade da ferramenta teve aprovação média de 86%. Conclusão: a representação gráfica da Bow-Tie provou ter importância na disseminação de diretrizes de segurança, facilitando o entendimento de prevenção e mitigação frente aos incidentes, assim como obteve aprovação dos profissionais que participaram do processo de construção das ferramentas, podendo este modelo ser replicado nas organizações de saúde para promoção da segurança do paciente.
Analyze the applicability of Bowtie tool as a resource for the dissemination of patient safety policy. Method: A descriptive and exploratory study on the quantitative approach has been carried out in a private hospital in the city of São Paulo, which was structured in two steps; first step was an analysis of Bowtie documents built by multi professional groups during planned workshops that took place from April to July 2014 in the morning, afternoon and night shifts; the second step was a comparative and relational analysis using Kruskal Wallis, Mann-Whitney and Spearman tests to become acquainted with the professionals’ opinion by means of a structured query with six affirmative sentences and five answer options, according to Likert’s scale (totally agree, agree, do not agree or disagree, disagree, totally disagree), a 95% confidence interval and 5% of error margin were employed in a population of professionals directly involved in patient care and who took part in the Bowties building workshops. Results: 19 workshops have been carried out with the participation of 505 subjects, 254 of them involved in assistive care. 127 Bowties have been built with 70 different subjects (47 regarding assistive care), two of which stood out as most prevalent: Medication Errors and Patient Falls. With respect to these 2 issues have been identified 29 and 22 hazards, 95 and 81 barriers, 19 and 12 consequences, respectively. The ratio barrier-hazard was 3.28 and 3.68 and the ratio of mitigation actions and consequences was 3.58 and 4.42, respectively. The opinion of the professionals regarding the applicability of the tool had an average approval of 86%. Conclusion: the Bowties graphic representation showed to be important in the dissemination of safety guidelines, enabling a better understanding of prevention and mitigation regarding incidents, and also obtained the approval of the professionals who took part in the process of tools building. This model can be replicated in health organizations to promote the safety of patients.
Analyze the applicability of Bowtie tool as a resource for the dissemination of patient safety policy. Method: A descriptive and exploratory study on the quantitative approach has been carried out in a private hospital in the city of São Paulo, which was structured in two steps; first step was an analysis of Bowtie documents built by multi professional groups during planned workshops that took place from April to July 2014 in the morning, afternoon and night shifts; the second step was a comparative and relational analysis using Kruskal Wallis, Mann-Whitney and Spearman tests to become acquainted with the professionals’ opinion by means of a structured query with six affirmative sentences and five answer options, according to Likert’s scale (totally agree, agree, do not agree or disagree, disagree, totally disagree), a 95% confidence interval and 5% of error margin were employed in a population of professionals directly involved in patient care and who took part in the Bowties building workshops. Results: 19 workshops have been carried out with the participation of 505 subjects, 254 of them involved in assistive care. 127 Bowties have been built with 70 different subjects (47 regarding assistive care), two of which stood out as most prevalent: Medication Errors and Patient Falls. With respect to these 2 issues have been identified 29 and 22 hazards, 95 and 81 barriers, 19 and 12 consequences, respectively. The ratio barrier-hazard was 3.28 and 3.68 and the ratio of mitigation actions and consequences was 3.58 and 4.42, respectively. The opinion of the professionals regarding the applicability of the tool had an average approval of 86%. Conclusion: the Bowties graphic representation showed to be important in the dissemination of safety guidelines, enabling a better understanding of prevention and mitigation regarding incidents, and also obtained the approval of the professionals who took part in the process of tools building. This model can be replicated in health organizations to promote the safety of patients.
Descrição
Citação
COSTA, Daniela Akemi. Aplicação da ferramenta bow-tie como recurso de disseminação da política de segurança do paciente. 2017. [124] p. Dissertação (Mestrado em Enfermagem) - Escola Paulista de Enfermagem (EPE), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2017.