IMPLEMENTAÇÃO DO CHECKLIST DE CIRURGIA SEGURA EM UM HOSPITAL UNIVERSITÁRIO
Resumo
Descritores: Cirurgia, Lista de verificação, Segurança do Paciente
IMPLEMENTATION OF SAFE SURGERY CHECKLIST IN A UNIVERSITY HOSPITAL
Objective: verify the implementation of safe surgery checklist in a multidisciplinary team through process of quality audit in a university hospital. Methods: Transversal and descriptive study, carried out between May and July 2015, in the surgical center of a public and university hospital. The surgeries were randomly monitored, and the dynamics of checklist filling by a multidisciplinary team was observed, comparing checklist filling performed in operating room with the one filled out by the study team. The data were analyzed by distribution, relative frequency and percentage. Results: Regarding checklist compliance, in 57% of accompanied surgeries patients identification was not performed, 100% of the staff did not introduced themselves in “time out” and not even confirmed orally the procedure in “sign out”. Conclusion: The checklist proposal of arousing staff for simple surgical procedure steps, but without which the potential for adverse events (AEs) is much larger, has not been achieved in clinical practice. Another important aspect is related to improvement of communication between multidisciplinary team which has not been contemplated in process.
Descriptors: Surgery, Checklist, Patient Safety
PERCEPCIÓN DEL HOMBRE MAYOR EN RELACIÓN CON SU SEXUALIDAD
Objetivo: Verificar la aplicación de la lista de verificación de cirugía segura entre los equipos multidisciplinarios para la calidad de la auditoría en hospital universitario. Métodos: Estudio transversal y descriptivo, realizado entre mayo y julio de 2015, en el centro quirúrgico de un hospital público y universitario. Cirugías aleatorios se acompañan, donde se observó aplicación dinámica de la lista de verificación por parte del equipo. Los datos fueron analizados mediante distribución, frecuencia relativa y porcentual. Resultados: La adhesión de la lista de verificación, en 57% de las cirugías acompañado la identificación de los pacientes no se realizó, 100% de los equipos no se presentó em tiempo y no confirmó el procedimiento cabo em signo. Conclusión: La lista de verificación propuesta, para despertar al equipo a los sencillos pasos del procedimiento quirúrgico, pero sin la cual, potencial de eventos adversos (EA) es mucho mayor, no se ha logrado en práctica clínica. Otro aspecto importante se refiere a mejora de la comunicación entre equipo multidisciplinario que no ha sido contemplado en proceso.
Descriptores: Cirurgía, Lista de Verificacíon, Seguridad del Paciente
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Hanchanale V, Rao AR, Motiwala H, Karim OMA. Wrong site surgery! How can we stop it? Urology Annals. [Internet]. 2014 [cited 2016 Sep 13]; 6(1): 57–62. Available from: http://www.urologyannals.com/temp/UrolAnn6157-3065453_083054.pdf
Jager E, Mckenna C, Bartlett L, Gunnarsson R, Ho YH. Postoperative adverse events inconsistently improved by the world health organization surgical safety checklist: a systematic literature review of 25 studies. World J of Surg. [Internet]. 2016 [cited 2016 Sep 13]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943979/
Filho GRM, Silva LFN, Ferracini AM, Bähr GL. Protocolo de cirurgia segura da OMS: o grau de conhecimento dos ortopedistas brasileiros. Rev bras ortop. [Internet]. 2013 [cited 2016 Sep 13]; 48(6): 554-62. Available from: https://ac.els-cdn.com/S2255497113001286/1-s2.0-S2255497113001286-main.pdf?_tid=a033db6c-f6d6-11e7-b8de-00000aab0f01&acdnat=1515678913_d97fc4dfa0951b96c5aa88387bb5cd4d.
Berrisford RG, Wilson IH, Davidge M, Sanders D. Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit. Eur J Cardiothorac Surg. [Internet] 2012. [cited 2016 Sep 16]; 41(6): 1326-1329. Available from: https://academic.oup.com/ejcts/article/41/6/1326/416664
Souza LP, Bezerra ALQ, Silva AEBC, Carneiro FS, Paranaguá TTB, Lemos LF. Eventos adversos: instrumento de avaliação do desempenho em centro cirúrgico de um hospital universitário. Revista enfermagem UERJ [Internet]. 2011 [cited 2016 Sep 21];19(1):127-13. Available from: http://www.facenf.uerj.br/v19n1/v19n1a21.pdf.
Gimenes FRE, Marques TC, Teixeira TCA, Mota MLS, Silva AEBC, Cassiani SHB. Medication wrong-route administrations in relation to medical prescriptions. Rev. Latino-Am. Enfermagem. [Internet]. 2011 [cited 2016 Sep 21]; 19(1): 11-7. Available from: http://www.scielo.br/pdf/rlae/v19n1/pt_03.pdf
Muniz RV, Bohrer BBA, Mulazzani MP, Erig LS, Santos SM, Santos HB. Criação e evolução da lista de verificação de cirurgia segura específica para oftalmologia. Revista Acreditação: ACRED. [Internet]. 2015 [cited 2016 Sep 13]; 5(9). Available from: http://dialnet.unirioja.es/servlet/articulo?codigo=5626618.
Martins GS, Carvalho R. Realização do time out pela equipe cirúrgica: facilidades e dificuldades. Revista SOBECC. [Internet]. 2014 [cited 2016 Sep 16]; 19(1). Available from: https://revista.sobecc.org.br/sobecc/article/view/49.
WHO. World Health Organization. World Health Organization: World Alliance for Patient Safety, Taxonomy. The Conceptual Framework for the International Classification for Patient Safety. Final Technical Report. January 2009, version 1,1. [cited 2016 Ago 12]. Available from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf.
Cabral RA, Eggenberger T, Keller K, Gallison BS, Newman D. Use of a Surgical Safety Checklist to Improve Team Communication. AORN Journal. [Internet]. 2016 [cited 2016 Sep 16]; 104(3): 206-16. Available from: file:///C:/Users/Usuario/Downloads/Cabral_et_al-2016-AORN_Journal.pdf
Pancieri AP, Santos BP, Avila MAG, Braga EM. Checklist de cirurgia segura: análise da segurança e comunicação das equipes de um hospital escola. Rev Gaúcha Enferm. [Internet]. 2013 [cited 2016 Sep 16]; 34(1):71-8. Available from: http://www.scielo.br/pdf/rgenf/v34n1/09.pdf.
Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. [Internet]. 2013 [cited 2016 Sep 16]. Available from: http://qualitysafety.bmj.com/content/qhc/23/4/299.full.pdf
Mehtsun WT, Ibrahim AM, West MD, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery. [Internet]. 2013 [cited 2016 Sep 16]; 153(4): 465-72. Available from: http://doi.org/10.1016/j.surg.2012.10.005 .
Santana HT, Siqueira HN, Costa MMM, Oliveira DCAN, Gomes SM, Sousa FC, et al. A segurança do paciente cirúrgico na perspectiva da vigilância sanitária - uma reflexão teórica. VISA em Debate: Sociedade, Ciência & Tecnologia. [Internet]. 2014 [cited 2016 Sep 25]; 2 (2). Available from: http://periodicos.fiocruz.br/pt-br/publicacao/8351 .
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. [Internet]. 2009 [cited 2016 Sep 25]; 360(5): 491-99. Available from: http://doi.org/10.1056/NEJMsa0810119 .
Fourcade A, Blache JL, Grenier C, Bourgain JL, Minvielle E. Barriers to staff adoption of a surgical safety checklist. BMJ Quality & Safety. [Internet]. 2011 [cited 2016 Sep 23]; 21(3): 191-7. Available from: http://doi.org/10.1136/bmjqs-2011-000094 .
Griffen FD. ACS Closed Claims Study reveals critical failures to communicate. Bull Am Coll Surg. [Internet]. 2007 [cited 2016 Sep 28]; 92(1):11-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17375480 .
Maziero ECS. Avaliação da implantação do Programa Cirurgia Segura em um hospital de ensino [dissertação] – Curitiba (PR). Universidade Federal do Paraná; 2012 [cited 2016 Sep 25]. Available from: http://acervodigital.ufpr.br/handle/1884/29376 .
Guzzo GM, Guimarães SM, Magalhães AMM. Efeitos e desafios da implantação de um sistema de verificação de segurança cirúrgica: revisão integrativa. J Nurs Health. [Internet]. 2014 [cited 2016 Sep 28]; 4 (2):155-64. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/enfermagem/article/view/3393 .
DOI: https://doi.org/10.21675/2357-707X.2017.v8.n4.972
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Esta obra está licenciada sob uma licença Creative Commons Atribuição 4.0 Internacional.
Eletrônico ISSN: 2357-707X
Impresso ISSN: 2177-4285
Este trabalho está licenciado com uma Licença Creative Commons - Atribuição 4.0 Internacional.