Tese (doutorado) - Universidade Federal de Santa Catarina, Centro Tecnológico, Programa de Pós-Graduação em Engenharia de Produção, Florianópolis, 2015. / Made available in DSpace on 2015-12-01T03:15:41Z (GMT). No. of bitstreams: 1
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Previous issue date: 2015 / O presente estudo foi desenvolvido com o objetivo propor diretrizes para impedir ocorrência do erro no preparo, administração e monitoramento de Medicamentos Potencialmente Perigosos (MPPs) por via intravenosa em um Serviço de Emergência Adulto num hospital escola, com ênfase na ergonomia, visando à segurança do paciente e trabalhadores. O estudo é classificado como um estudo de caso de natureza aplicada, com abordagem quantitativa e qualitativa, embasado em pesquisa exploratória de desenho transversal, em razão da intencionalidade da escolha da população. A população investigada constituiu-se de 34 técnicos e 06 auxiliares de enfermagem. Os dados foram levantados em dois momentos. O primeiro, no período de 15 a 21 de novembro de 2013, quando foi aplicado o questionário e o segundo, no período de 15 a 26 de janeiro de 2014, com a observação. Nesta fase, foram observados e identificados os erros ocorridos durante o preparo, a administração e o monitoramento de 23 doses de MPPs com o uso do Checklist. Os dados do questionário indicaram, dentre outros, que dos 40 sujeitos da pesquisa 27 (67,5%) não fizeram a leitura da bula do cloreto de potássio, 32 (80,0%) não fizeram a leitura da bula do sulfato de magnésio e 45,0% (n=18) não fizeram a leitura da bula da glicose. Os resultados da observação permitiram identificar que, dos 54 itens do Checklist, em 43 (79,6%) ocorreram erros. Nenhum dos erros causou impactos para o paciente, um causou dano material e todos foram classificados como violação. Propõe-se, como medidas para impedir a ocorrência dos erros nessa instituição, a elaboração de protocolos de preparo e administração de medicamentos; a promoção de educação continuada e permanente para os profissionais sobre o tema; e a formação de um grupo multiprofissional com a finalidade de discutir e estabelecer estratégias que possam promover a segurança do paciente.<br> / Abstract : This study was developed with the objective of offerring guidelines to stop errors in preparing, managing and monitoring Potencially Dangerous Drugs (MPPs) pushed through intravenous via at an Adult Emergency Service, with ergonomic emphasis, aiming pacient?s and workers safety. The study is classified as an apllied nature case study, with qualitative and quantitative approach, based on exploratory research of transversal design, because the choice of the population was intentional. This population was constituted of 34 technicians and 06 nursing helpers. The data was raised in two moments. The first, during november 15th and 21st of 2013, when a questionnaire was applied; the second moment took place during january 15th and 26th of 2014, with observation. At this point, the errors occurred during preparation, managing and monitoring of 23 doses of MPPs with the use of checklist. The questionnaire data indicated, along with other facts, that 27 of the 40 people interviewed (67,5%) did not read the potassium chloride bull; 32 (80,0%) did not read the magnesium sulfate bull and 45,0% (18 people) did not read the glucose bull. The results allowed to identify that errors occurred in 43 of the 54 items of the checklist (79,6%). None of the errors caused impacts on the patient; one caused material damage and all errors were classified as violation. Within the major errors identified during preparation of the 23 doses, 23 (100,0%) of the professionals did not verify prescription before iniciating the process; 23 (100,0%) did not verify the expiration date, particle presence and solution turbidity; 23 (100,0%) of the professionals didn?t do the second and third label readings. In the managing section, 23 (100,0%) did not use the tray to transport medication; 23 (100,0%) didn?t wash their hands before iniciating drug administration; 21 (91,3%) did not identify the paciente by their name; 17 (74,0%) didn?t check the drug?s name; the dose was not checked by 23 (100,0%) professionals before it was managed and 11 individuals (47,8%) did not test the venous permeability. Besides, all 23 people didn?t do the pacient?s monitoring. It can be concluded that facts like work conditions of technicians and nursing helpers, overcrowding, reduced number of professionals, work organization, double bond and the extensive working hours, beyond others, are factors that favor the errors incidence in medication, and are present in the SEA of the studied institution. It is proposed, as measures to stop errors incidence in this institution, the elaboration of preparation and managing drugs protocols, the promotion of continued andpermanent education for professionals and the criation of a multiprofissional group with the objective of discussing and establishing strategies to promote pacient?s safety.
| Identifer | oai:union.ndltd.org:IBICT/oai:repositorio.ufsc.br:123456789/156763 |
| Date | January 2015 |
| Creators | Seitz, Eva Maria |
| Contributors | Universidade Federal de Santa Catarina, Merino, Eugenio Andrés Díaz |
| Source Sets | IBICT Brazilian ETDs |
| Language | Portuguese |
| Detected Language | English |
| Type | info:eu-repo/semantics/publishedVersion, info:eu-repo/semantics/doctoralThesis |
| Format | 364 p.| il., grafs., tabs. |
| Source | reponame:Repositório Institucional da UFSC, instname:Universidade Federal de Santa Catarina, instacron:UFSC |
| Rights | info:eu-repo/semantics/openAccess |
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