Root Cause Analysis, Failures and Effects in pediatric total quality management: a scoping review

Abstract

Objectives: to analyze the applicability of Root Cause Analysis and Failure Mode and Effect Analysis tools, aiming to improve care in pediatric units. Methods: this is a scoping review carried out according to the Joanna Briggs Institute guidelines, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews. Search took place in May 2018 on 15 data sources. Results: search totaled 8,254 studies. After using the relevant inclusion and exclusion criteria, 15 articles were included in the review. Of these, nine were published between 2013 and 2018, 12 used Failure Mode and Effect Analysis and 11 carried out interventions to improve the quality of the processes addressed, showing good post-intervention results. Final Considerations: the application of the tools indicated significant changes and improvements in the services that implemented them, proving to be satisfactory for detecting opportunities for improvement, employing specific methodologies for harm reduction in pediatrics.

Prevalence of Adverse Events Reported in a Hospital Environment

“…Dentre as ferramentas de gestão pode ser citado o mais utilizado, Análise da Causa Raiz, para identificar a verdadeira causa e o "por quê? ", não apenas quem e o que aconteceu, evitando assim a cultura de culpabilização do profissional e inserindo uma análise sistêmica do erro (Lima, et al 2021).…”

Ferramentas de gestão de risco na segurança do paciente suicida em emergências hospitalares

“…Outros autores relatam que o HFMEA possibilita ações proativas de prevenção ao evento, além de uma análise da causa principal que gerou o incidente. Além disso, tem como objetivo levantar os riscos, avaliar e sugerir o controle dos incidentes para que não ocorram e assim ampliar benefícios para a assistência de qualidade e com risco menor de dano ao paciente (Pasa, Magnano & Urbanetto, 2021;Abi et al, 2022;Lima et al, 2021;Moraes, Rabin & Viegas, 2018).…”

Root cause analysis of safety incidents in antineoplastic use in children

“…Using appropriate tools is essential to identify, analyze contributing factors and propose solutions to observed problems and incidents ( 15 ) . Among these, root cause analysis (RCA) is a systematic, relatively simple investigation strategy that seeks to understand the causes of the incident ( 16 - 17 ) .…”

“…RCA is a method that leads to a greater understanding of the cause of the accident, with less focus on the individual who committed the error and more information on organizational factors. It helps to identify the reason for the occurrence, and not just describe the event ( 17 - 18 ) . It is a low-cost strategy that helps mitigate medication errors.…”