Impact of Plan-Do-Study-Act Cycles on the Reduction of Errors Related to Vaccine Administration

Abstract

Objective: to evaluate the impact of a quality improvement program in the reduction of errors related to vaccine administration. Method: an intervention study aimed at comparing outcome measures before (Phase I) and after (Phase II) the implementation of a quality improvement program. It was carried out in a Basic Health Unit in the inland of São Paulo from March 2019 to November 2019. In the first phase, there was direct observation by Nursing professionals during the preparation and administration of the doses. In the second phase, an error was selected and subjected to four Plan-Do-Study-Act cycles to test the changes. The following quality tools were also used: root cause analysis, Ishikawa diagram and Pareto diagram. Results: a total of 164 doses of vaccines prepared and administered to 51 users were observed; 527 errors were identified and categorized into 13 types. In 27.7% of the observations made in Phase I, the users/guardians were not informed about potential adverse reactions. The goal of 100% of guidelines was established over an eight-month period, which was achieved in the second Plan-Do-Study-Act cycle and maintained in the third and fourth cycles, with confirmed improvement in the process. Conclusion: the quality improvement approach, based on Plan-Do-Study-Act cycles, contributed to the reduction of errors in the administration of vaccines and the change was sustainable, as it maintained over time.

Impacto de um programa de melhoria da qualidade nos erros de preparo e administração de medicamentos orais via sonda nasoenteral: estudo de intervenção

“…Para melhorar processos, é preciso conhecer profundamente o sistema que se pretende mudar, além disso, é indispensável o uso de métodos de melhoria para auxiliar os pesquisadores e/ou líderes organizacionais. Essa união favorece a melhoria dos processos, conforme demonstrado em pesquisas prévias (COSTA, 2021;NUNES, 2020;NUNES, 2021;PEREIRA et al, 2020;COPE, M. et al, 2017). Deming dedicou parte do seu trabalho registrando "o que fazer" para melhorar os processos por meio do conhecimento profundo (DEMING, 1900)…”

“…Pesquisadora elaborou um gráfico de tendência para acompanhar e monitorar a variável orientações aos usuários e/ ou responsável sobre as possíveis reações adversas. A partir do terceiro ciclo PDSA, a variável atingiu 100% de orientações (Nunes, 2021).…”