Universidade Federal do Rio de Janeiro. Rio de Janeiro, Rio de Janeiro, Brazil.
Instituto Nacional de Câncer. Rio de Janeiro, Rio de Janeiro, Brazil.
Rev Bras Enferm. 2024 Jul 15;77Suppl 3(Suppl 3):e20230139. doi: 10.1590/0034-7167-2021-0139. eCollection 2024.
to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients.
a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors.
in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages.
the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.
识别和分析导致儿科肿瘤患者在开具、准备和分发抗肿瘤药物过程中发生安全事件的因素。
一项质量改进研究侧重于肿瘤儿科药物治疗过程，该研究在 2019-2020 年期间识别和分析了事件。一个多学科小组进行了根本原因分析（RCA），确定了主要的促成因素。
2019 年记录了 7 起事件，其中 57%与处方有关。2020 年，通过主动搜索，确定了 34 起事件，其中 65%与处方有关，29%与准备有关，6%与分发有关。主要促成因素包括中断、缺乏电子警报、工作负荷过重、培训和人员短缺。
结果表明，充分记录和应用 RCA 对已识别事件的分析可以提高儿科肿瘤护理质量，映射促成因素，并使管理人员能够制定有效的行动计划，以减轻与该过程相关的风险。
