Improvement project to reduce surgical site infections: a retrospective cohort study.

INTRODUCTION: Surgical site infections are one of the main problems related to health care. In Brazil, they are responsible for 14 to 16% of infections related to health care. This study sought to analyze the effect of implementing a package of measures to reduce surgical site infections (SSI) in heart surgeries, kidney transplants and herniorrhaphies and to evaluate adherence to the safe surgery checklist in a university hospital. METHODS: this is a retrospective cohort study with data collection in a time series for the period from 2018 to 2020. RESULTS: we analyzed 222 medical records referring to the surgeries under study performed in the year 2020, in which data were collected from the patients and the care package prevention measures. SSI data and adherence to the safe surgery checklist were analyzed in the years 2018, 2019 and 2020, totaling 268, 300 and 222 procedures analyzed, respectively. CONCLUSION: the study showed a significant reduction in the SSI rate with greater adherence to the protocol, which was not maintained and was influenced by the COVID-19 pandemic. Thus, the sustainability of this action represents a challenge to be overcome, in order to establish a safer environment for the patient and a better quality of service.

Quality of prescription writing in Brazilian primary health care.

OBJECTIVE: To evaluate the quality of prescription writing in the context of public primary health care. BACKGROUND: Prescription errors are one of the leading patient safety problems in primary care and can be caused by errors in therapeutic decisions or in the quality of prescription writing. METHODS: Cross-sectional observational study conducted in a municipality in Northeastern Brazil. The assessment instrument (including 13 indicators and one composite indicator) was applied to a representative sample of drug prescriptions from the 24 Family Health Teams providing Primary Health Care in the municipality, dispensed in January 2021. Estimates of compliance and their 95% confidence intervals and graphical analysis of frequencies are assessed globally and stratified by dispensing units and prescribers. FINDINGS: The average composite prescription writing quality on a 0-100 scale was 60.2 (95% CI 57.8-62.6). No quality criteria had 100% compliance. The highest compliance rates were found for 'frequency of administration' (98.9%) and 'identification of the prescriber' (98.9%). On the other hand, 'recorded information on allergy' (0.0%), 'patient's date of birth' (1.7%), 'nonpharmacological recommendations' (1.7%), and 'guidance on the use of the drug' (25%) were the indicators with lower compliance, contributing to 69% of the noncompliances found. The type and frequency of the errors in the quality of prescription writing uncovered in this study confirm the continuing need to tackle this problem to improve patient safety. The results identify priority aspects for interventions and further studies on the quality of prescription writing in the context of Primary Health Care in Brazil.

Validation of surgical care quality indicators in the Brazilian Unified Health System.

OBJECTIVE: To validate a set of indicators for monitoring the quality of surgical procedures in the Brazilian Unified Health System (SUS). METHODS: Validation study developed in 5 stages: 1) literature review; 2) prioritization of indicators; 3) content validation of indicators by RAND/UCLA consensus method; 4) pilot study for reliability analysis; and 5) development of instruction for tabulation of outcome indicators for monitoring via official information systems. RESULTS: From the literature review, 217 indicators of surgical quality were identified. The excluded indicators were: those based on scientific evidence lower than 1A, similar, specific, which corresponded to sentinel events; and those that did not apply to the SUS context. Twenty-six indicators with a high level of scientific evidence were submitted to expert consensus. Twenty-two indicators were validated, of which 14 process indicators and 8 outcome indicators with content validation index ≥80%. Of the validated process indicators, 6 were considered substantially reliable (Kappa coefficient between 0.6 and 0.8; p < 0.05) and 2 had almost perfect reliability (Kappa coefficient > 0.8, p < 0.05), when the inter-rater agreement was analyzed. One could measure and establish tabulation mechanism for TabWin for 7 outcome indicators. CONCLUSION: The study contributes to the development of a set of potentially effective surgical indicators for monitoring the quality of care and patient safety in SUS hospital services.

Effects of home healthcare for adults with chronic respiratory diseases and post-COVID-19 syndrome on hospital bed turnover rate: a protocol of systematic review with meta-analysis.

INTRODUCTION: Chronic respiratory diseases (CRDs) have a high prevalence, morbidity and mortality worldwide. After the COVID-19 pandemic, the number of patients readmitted after hospital discharge increased. For some populations, early hospital discharge and home healthcare may reduce health costs in patients treated at home when compared with those hospitalised. This study aims to systematically review the effectiveness of home healthcare for patients with CRDs and post-COVID-19 syndrome. METHODS AND ANALYSIS: We will search on MEDLINE, CENTRAL, Embase and PsycINFO. We will include randomised controlled trials (RCTs) and non-RCT studies reported in full text and abstracts. No language restriction will be applied. We will include studies related to adults with a diagnosis of CRDs or post-COVID-19 syndrome that compared in-patient hospital care with any home healthcare. We will exclude studies with participants with neurological, mental diseases, cancer or pregnant women. Two review authors will screen abstracts and select the eligible studies. To investigate the risk of bias, we will use the Cochrane 'Risk of Bias' tool for RCT, and the Risk of Bias In Non-randomised Studies-of Interventions for non-RCT. We will use the five Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) considerations to assess the quality of the evidence. Patients and the public will be involved in the preparation, execution and implementation phases of the review. ETHICS AND DISSEMINATION: No ethical approval is required because only published data will be analysed. The publication of the results in peer-reviewed journals and at relevant conferences will guide the direction of future research in the field and healthcare practice. The results will also be disseminated in plain language on social media to disseminate the knowledge to society and the public interested in the topic.

Instruments for assessing quality policies and strategies in health systems: a scoping review protocol.

INTRODUCTION: The World Organization recommends to implement National Quality Policies and Strategies in health systems, but few instruments have been proposed to assess and monitor these quality interventions at the system level. This study will map and compare instruments for the assessment of quality policies and strategies in health systems around the world. METHODS AND ANALYSIS: This is a scoping review protocol developed according to the Joanna Briggs Institute's manual and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. The search for articles will be performed in the following Embase, Medline/Pubmed, Scopus, Web of Science and Cumulative Index to Nursing and Allied Health Literature. Searches will also be conducted on Google Scholar and grey literature (www.opengrey.eu). A descriptive analysis of studies mapped by analysis categories will be performed. The results will be presented through a narrative summary of the mapped findings to verify how the results correlate with the objective and research question of the review. ETHICS AND DISSEMINATION: The study does not require an ethical review due to its nature. The submission of results for publication in a peer-reviewed journal and presentation at a scientific conference is expected. LINK TO THE PROTOCOL RECORD IN THE OPEN SCIENCE FRAMEWORK OSF: https://DOI.org/10.17605/OSF.IO/2KMTS.

Improvement project to reduce surgical site infections: a retrospective cohort study / Projeto de melhoria para redução de infecções de sítio cirúrgico: um estudo de coorte retrospectivo

ABSTRACT Introduction: Surgical site infections are one of the main problems related to health care. In Brazil, they are responsible for 14 to 16% of infections related to health care. This study sought to analyze the effect of implementing a package of measures to reduce surgical site infections (SSI) in heart surgeries, kidney transplants and herniorrhaphies and to evaluate adherence to the safe surgery checklist in a university hospital. Methods: this is a retrospective cohort study with data collection in a time series for the period from 2018 to 2020. Results: we analyzed 222 medical records referring to the surgeries under study performed in the year 2020, in which data were collected from the patients and the care package prevention measures. SSI data and adherence to the safe surgery checklist were analyzed in the years 2018, 2019 and 2020, totaling 268, 300 and 222 procedures analyzed, respectively. Conclusion: the study showed a significant reduction in the SSI rate with greater adherence to the protocol, which was not maintained and was influenced by the COVID-19 pandemic. Thus, the sustainability of this action represents a challenge to be overcome, in order to establish a safer environment for the patient and a better quality of service.

RESUMO Introdução: as infecções do sítio cirúrgico são um dos principais agravos relacionados à assistência à saúde. No Brasil, são responsáveis por 14 a 16% das infecções relacionadas à assistência à saúde. Esse estudo buscou analisar o efeito da implementação de um pacote de medidas para redução de infecções de sítio cirúrgico (ISC) em cirurgias cardíacas, transplantes renais e herniorrafias e avaliar adesão ao checklist de cirurgia segura em um hospital universitário. Métodos: trata-se de um estudo de coorte retrospectivo com coleta de dados em série temporal relativo ao período de 2018 a 2020. Resultados: foram analisados 222 prontuários referentes às cirurgias em estudo realizadas no ano de 2020, nos quais foram coletados dados dos pacientes e do pacote de medidas de prevenção. Dados de ISC e adesão ao checklist de cirurgia segura foram analisados nos anos de 2018, 2019 e 2020, totalizando 268, 300 e 222 procedimentos analisados, respectivamente. Conclusão: o estudo evidenciou uma redução significativa da taxa de ISC com a maior adesão ao protocolo, a qual não foi mantida e sofreu influência da pandemia de COVID-19. Assim, a sustentabilidade dessa ação representa um desafio a ser contornado, a fim de estabelecer um ambiente mais seguro para o paciente e uma melhor qualidade do serviço.

Validation of surgical care quality indicators in the Brazilian Unified Health System / Validação de indicadores de qualidade do cuidado cirúrgico no Sistema Único de Saúde

ABSTRACT OBJECTIVE To validate a set of indicators for monitoring the quality of surgical procedures in the Brazilian Unified Health System (SUS). METHODS Validation study developed in 5 stages: 1) literature review; 2) prioritization of indicators; 3) content validation of indicators by RAND/UCLA consensus method; 4) pilot study for reliability analysis; and 5) development of instruction for tabulation of outcome indicators for monitoring via official information systems. RESULTS From the literature review, 217 indicators of surgical quality were identified. The excluded indicators were: those based on scientific evidence lower than 1A, similar, specific, which corresponded to sentinel events; and those that did not apply to the SUS context. Twenty-six indicators with a high level of scientific evidence were submitted to expert consensus. Twenty-two indicators were validated, of which 14 process indicators and 8 outcome indicators with content validation index ≥80%. Of the validated process indicators, 6 were considered substantially reliable (Kappa coefficient between 0.6 and 0.8; p < 0.05) and 2 had almost perfect reliability (Kappa coefficient > 0.8, p < 0.05), when the inter-rater agreement was analyzed. One could measure and establish tabulation mechanism for TabWin for 7 outcome indicators. CONCLUSION The study contributes to the development of a set of potentially effective surgical indicators for monitoring the quality of care and patient safety in SUS hospital services.

RESUMO OBJETIVO Validar um conjunto de indicadores para monitoramento da qualidade dos procedimentos cirúrgicos no Sistema Único de Saúde (SUS). MÉTODOS Estudo de validação desenvolvido em 5 etapas: 1) revisão de literatura; 2) priorização de indicadores; 3) validação de conteúdo dos indicadores por método de consenso RAND/UCLA; 4) estudo piloto para análise da confiabilidade; e 5) desenvolvimento de instrutivo para tabulação dos indicadores de resultado para monitoramento via sistemas de informações oficiais. RESULTADOS A partir da revisão de literatura, foram identificados 217 indicadores de qualidade cirúrgica. Os indicadores excluídos foram: indicadores baseados em evidências científicas inferiores a 1A, similares, específicos, que correspondiam a eventos sentinelas; e aqueles que não se aplicavam ao contexto do SUS. Foram submetidos ao consenso de especialistas 26 indicadores com alto nível de evidência científica. Foram validados 22 indicadores, dos quais 14 indicadores de processo e 8 indicadores de resultado com índice de validação de conteúdo ≥80%. Dos indicadores de processo validados, 6 foram considerados confiáveis substancialmente (Coeficiente de Kappa entre 0,6 e 0,8; p < 0,05) e 2 tiveram confiabilidade quase perfeita (coeficiente de Kappa > 0,8, p < 0,05), quando analisada a concordância interavaliador. Foi possível mensurar e estabelecer mecanismo de tabulação para TabWin para 7 indicadores de resultado. CONCLUSÃO O estudo contribui com o desenvolvimento de um conjunto de indicadores cirúrgicos potencialmente eficazes para o monitoramento da qualidade do cuidado e segurança do paciente nos serviços hospitalares do SUS.

Framework for health care quality and evidence-based practice in radiology departments: A regional study on radiographer's perceptions.

INTRODUCTION: The main goals of this study were to describe, in an integrated and multidimensional way, the conditions related to the quality of care in radiology departments from Algarve (Portugal), to assess the perspective of radiographers on the use of scientific evidence in clinical practice and to validate a model that characterizes the conditions for continuous improvement. METHODS: A cross sectional study was performed in four radiology departments from public and private healthcare facilities from Algarve region (Portugal). A paper-based survey was sent to all radiographers to assess the quality systems implemented in their radiology departments and their perspective on the use of scientific evidence in clinical practice. RESULTS: In total, 62 radiographers (61.4%) completed the survey. The quality dimensions that obtained the highest degree of compliance were the existence of quality assurance and improvement activities (43.0%), existence of standards in clinical practice of radiographers (42.7%) and the existence of special provisions (37.6%). The quality dimension related to patient's involvement was the one with the lowest level of compliance. Moreover, from the radiographers perspective, positive responses were obtained related to evidence-based actions (83.0%), sources of evidence (76.0%) and the significance of research activities (74.0%). CONCLUSION: These findings suggest that a new framework based on four factors (Support for Information; Organizational Capability to Technical Quality of Care; Patient Involvement and Evidence-Based Radiology), should be considered in the establishment of strategic policies that better define the provision of diagnostic procedures and professional practices in radiology departments from Algarve region, based on quality improvement systems and better patient safety. IMPLICATIONS FOR PRACTICE: There is a need to include patients in the decision-making process, to involve radiographers in quality assurance and improvement activities and to implement quality monitoring mechanisms within radiology departments under study.

Impact of the implementation of the WHO Safe Childbirth Checklist on essential birth practices and adverse events in two Brazilian hospitals: a before and after study.

OBJECTIVE: The WHO Safe Childbirth Checklist (SCC) is a promising initiative for safety in childbirth care, but the evidence about its impact on clinical outcomes is limited. This study analysed the impact of SCC on essential birth practices (EBPs), obstetric complications and adverse events (AEs) in hospitals of different profiles. DESIGN: Quasi-experimental, time-series study and pre/post intervention. SETTING: Two hospitals in North-East Brazil, one at a tertiary level (H1) and another at a secondary level (H2). PARTICIPANTS: 1440 women and their newborns, excluding those with congenital malformations. INTERVENTIONS: The implementation of the SCC involved its cross-cultural adaptation, raising awareness with videos and posters, learning sessions about the SCC and auditing and feedback on adherence indicators. PRIMARY AND SECONDARY OUTCOME MEASURES: Simple and composite indicators related to seven EBPs, 3 complications and 10 AEs were monitored for 1 year, every 2 weeks, totalling 1440 observed deliveries. RESULTS: The checklist was adopted in 83.3% (n=300) of deliveries in H1 and in 33.6% (n=121) in H2. The hospital with the highest adoption rate for SCC (H1) showed greater adherence to EBPs (improvement of 50.9%;p<0.001) and greater reduction in clinical outcome indicators compared with its baseline: percentage of deliveries with severe complications (reduction of 30.8%;p=0.005); Adverse Outcome Index (reduction of 25.6%;p=0.049); Weighted Adverse Outcome Score (reduction of 39.5%;p<0.001); Severity Index (reduction of 18.4%;p<0.001). In H2, whose adherence to the SCC was lower, there was an improvement of 24.7% compared with before SCC implementation in the composite indicator of EBPs (p=0.002) and a reduction of 49.2% in severe complications (p=0.027), but there was no significant reduction in AEs. CONCLUSIONS: A multifaceted SCC-based intervention can be effective in improving adherence to EBPs and clinical outcomes in childbirth. The context and adherence to the SCC seem to modulate its impact, working better in a hospital of higher complexity.

Confiabilidade da autoavaliação das práticas de segurança do paciente instituídas pelo Sistema Nacional de Vigilância Sanitária: um estudo piloto / Reliability of patient safety self-assessment practices established by the National Health Surveillance System: a pilot study

Resumo Introdução: A Autoavaliação das Práticas de Segurança do Paciente é um ato regulatório para melhoria da qualidade do cuidado. Porém, há dúvidas sobre a validade das suas informações. O objetivo deste estudo foi analisar a sua confiabilidade. Método: Estudo piloto de análise da confiabilidade de 21 indicadores simples e um composto da autoavaliação como forma de embasar uma amostra nacional em estudos futuros. Participaram hospitais com leitos de terapia intensiva e comparou dados da Autoavaliação (AA) e Autoavaliação Revisada (AR) pela vigilância sanitária (Visa) com a Inspeção Presencial (IP). A análise incluiu os coeficientes Kappa e de correlação intraclasse. Resultados: Comparando com a IP, a concordância foi aceitável (Kappa≥0,4) em 12 indicadores da AA e em 18 da AR. Os indicadores menos confiáveis são relativos a protocolos de prevenção de infecções. Quanto ao indicador composto do nível de adesão, a confiabilidade melhorou com revisão da Visa (AA=0,89 e AR=0,94), embora a concordância da classificação de alta conformidade tenha sido baixa. Conclusões: A AR se mostrou essencial para melhorar a confiabilidade da Autoavaliação. Ademais, identificou-se necessidade de revisar alguns indicadores e o instrumento de verificação pela Visa.

Abstract Introduction: The Patient Safety Self-Assessment Practices is a regulatory action to enhance quality of care. However, validation of its information requires attention. This study aimed to analyze reliability of the Patient Safety Self-Assessment Practices. Methods: Pilot study analyzing the reliability of 21 simple indicators and 1 composite of self-assessment to provide a national sample in future studies. Hospitals with intensive unit care beds participated in the study, and data from self-assessment (SA) and revised self-assessment (RSA) by the health surveillance (HS) were compared with on-site inspection (OSI). Analyses included Kappa and intraclass correlation coefficients. Results: Concordance was satisfactory (Kappa ≥ 0.4) in 12 indicators of SA and 18 indicators of RSA compared with OSI. The least reliable indicators were related to infection prevention protocols. Reliability of the adherence level composite indicator improved with HS revision (SA = 0.89 and RSA = 0.94), despite the low concordance of the high compliance classification. Conclusion: RSA was essential to improve reliability of SA. In addition, some indicators and assessment tools of the HS need revision.

Improvement of quality of care for gestational syphilis in the municipality of Rio de Janeiro.

OBJECTIVE: To analyze the effect of a multifaceted intervention in the care of pregnant women with syphilis in primary health care. METHODS: This is a quality improvement project performed in 26 basic care units in the municipality of Rio de Janeiro, between January and December 2017. It has a quasi-experimental mixed design, with previous, later and time series analyses. We evaluated the care provided to all pregnant women with syphilis whose prenatal care that ended during the studied period, using ten quality criteria and one indicator. The intervention was multifaceted, covering permanent education, improvement of records and information systems, audit and feedback, patient education, organizational changes and work processes. We estimated absolute and relative improvements of the criteria and their statistical significance (α = 5%). The facilitators and hinders of the intervention were analyzed according to the Model for Understanding Success in Quality. RESULTS: After the intervention, there was a total absolute improvement of 6.7% (64.4% versus 71.0%) and relative of 28.8% (p > 0.05). Eight of the ten quality criteria had an improvement, which was significant in four of them (p < 0.05). The monthly indicator of adequate treatment also improved (p < 0.05), but maintained low performance throughout the project. The increase in the compliance of the treatment scheme with the protocol (91.4% versus 99.1%) positively stood out, but the main opportunities for improvement were testing (42.8% versus 48.5%) and treatment of sexual partnerships (42.8% versus 44.2%). Regulatory pressures to improve the monthly indicator and the political-economic crisis experienced by the municipality modulated the effect of the intervention. CONCLUSION: The project was useful to identify priorities and guide interventions to improve the quality of care for syphilis, although there is still ample room for improvement. The identified problems, as well as the contextual modulators of the effect, should be considered in future interventions.

Implementation of an improvement cycle in the care of a primary health care.

OBJECTIVES: to evaluate the effectiveness of a quality improvement cycle applied to the care of spontaneous demand in a primary care center. METHODS: quasi-experimental before and after study, with a quantitative approach and no control group. An improvement cycle was carried out in a primary care center in the city of Guarabira/PB using five quality criteria. An evaluation, an intervention focused on the most problematic criterion and a reassessment were carried out. The samples were random (n = 60). The percentages and confidence intervals of compliance with each criterion were verified. Statistical significance was calculated using the Z test. RESULTS: after the intervention, there was a significant improvement in two quality criteria of the care of spontaneous demand users (the user must be heard by a professional and go through the risk classification). CONCLUSIONS: the improvement cycle was an effective quality management method.

Development and validation of process indicators of the quality of nursing care for the elderly / Desenvolvimento e validação de indicadores de processo da qualidade da assistência de enfermagem ao idoso

INTRODUCTION: Quality indicators are important for service management. However, in primary care, there is a shortage of indicators specifically regarding the elderly population. OBJECTIVE: To build and validate process indicators of the quality of nursing care for the elderly. METHODS: This is a methodological research, and the steps are based on proposals from the National Database of Nursing Quality Indicators and the Agency for Healthcare Research and Quality. The indicators were evaluated according to the criteria of face validity, terminology, necessity, content validity, reliability, viability, utility, and usability. Nine nurses participated in the expert panel, including professionals who provided primary care assistance, researchers in the area of health care for the elderly, and members of Brazilian health-related organizations. The Adequacy Method developed by Research and Development at the University of California Los Angeles was used. Data were analyzed using the median, Content Validity Index, and Kappa. RESULTS: Twenty-two indicators were validated. All measures were considered appropriate, with content validity, and reached an agreement on terminology and necessity. Of the 22 indicators, only four were considered unavailable and impractical to collect. Thirteen indicators were not considered useful for determining the reception of financial incentives. In the assessment of usability to compare public reports, six indicators had relatively low scores. CONCLUSION: Indicators can contribute to monitoring the quality of care for the elderly, identifying opportunities for improvement in actions performed by nurses in primary care.

INTRODUÇÃO: Os indicadores de qualidades são aspectos importantes na gestão dos serviços. No entanto, na atenção primária, há escassez de indicadores especificamente no que concerne à população idosa. OBJETIVO: Construir e validar indicadores de processo da qualidade da assistência de enfermagem ao idoso. MÉTODOS: Trata-se de uma pesquisa metodológica, sendo as etapas baseadas nas propostas da National Database of Nursing Quality Indicators e da Agency for Healthcare Research and Quality. Os indicadores foram avaliados segundo os critérios de: validade de face, terminologia, necessidade, validade de conteúdo, confiabilidade, viabilidade, utilidade e usabilidade. Participaram do painel de especialistas nove enfermeiros sendo profissionais que prestavam assistência na atenção primária, pesquisadores na área de atenção à saúde do idoso e membros de organizações brasileiras relacionadas à saúde. Foi utilizado o Método de Adequação desenvolvido pela Research and Development da University of California Los Angeles. Os dados foram analisados por meio da mediana, Índice de Validade de Conteúdo e Kappa. RESULTADOS: Foram validados 22 indicadores. Todas as medidas foram consideradas apropriadas, com validade de conteúdo e obtiveram acordo acerca da terminologia e necessidade. Dentre os 22 indicadores, apenas quatro foram avaliados como não disponíveis e não viáveis para serem coletados. Treze indicadores não foram considerados úteis para determinar o recebimento de incentivos financeiros. Na avaliação sobre a usabilidade para comparar os relatórios públicos, seis indicadores obtiveram pontuação relativamente baixa. CONCLUSÃO: Os indicadores podem contribuir para o monitoramento da qualidade da assistência ao idoso, identificando oportunidades de melhoria nas ações realizadas pelo enfermeiro na atenção primária.

Adverse obstetric outcomes in two Brazilian maternity hospitals.

PURPOSE: Obstetric adverse outcomes (AOs) are an important topic and the use of composite measures may favor the understanding of their impact on patient safety. The aim of the present study was to estimate AO frequency and obstetric care quality in low and high-risk maternity hospitals. DESIGN/METHODOLOGY/APPROACH: A one-year longitudinal follow-up study in two public Brazilian maternity hospitals. The frequency of AOs was measured in 2,880 randomly selected subjects, 1,440 in each institution, consisting of women and their newborn babies. The frequency of 14 AOs was estimated every two weeks for one year, as well as three obstetric care quality indices based on their frequency and severity as follows: the Adverse Outcome Index (AOI), the Weighted Adverse Outcome Score and the Severity Index. FINDINGS: A significant number of mothers and newborns exhibited AOs. The most prevalent maternal AOs were admission to the ICU and postpartum hysterectomy. Regarding newborns, hospitalization for > seven days and neonatal infection were the most common complications. Adverse outcomes were more frequent at the high-risk maternity, however, they were more severe at the low-risk facility. The AOI was stable at the high-risk center but declined after interventions during the follow-up year. ORIGINALITY/VALUE: High AO frequency was identified in both mothers and newborns. The results demonstrate the need for public patient safety policies for low-risk maternity hospitals, where AOs were less frequent but more severe.

Massive online open course como estratégia para o ensino de segurança no processo de medicação / Massive online open course as a strategy for teaching medication safety

Resumo: Introdução: Erros de medicação são comuns e causam sofrimento e custos que podem ser evitados. A mitigação da ocorrência de eventos adversos a medicamentos é tratada como prioridade pela Organização Mundial da Saúde (OMS), que recomenda a inclusão do tema segurança do paciente nos currículos das profissões de saúde como medida para minimizar danos aos pacientes. Um curso on-line aberto e massivo (MOOC) sobre segurança no processo de medicação foi desenvolvido como estratégia educacional para a área da saúde e disponibilizado no Ambiente Virtual de Aprendizagem do Sistema Único de Saúde (Avasus), em março de 2018. Objetivo: Este estudo teve como objetivo avaliar a satisfação e o aprendizado dos participantes que concluíram o curso. Método: Trata-se de estudo de delineamento quase experimental não controlado. O MOOC possui uma carga horária de 30 horas e aborda temas sobre segurança na prescrição, dispensação, administração e notificação de incidentes relacionados a medicamentos. Aplicaram-se um pré-teste e um pós-teste de múltipla escolha para avaliar o nível de conhecimento dos participantes, e um questionário de satisfação foi respondido ao término do curso. Analisaram-se a confiabilidade dos instrumentos de medida, a significância da melhoria do conhecimento e os fatores associados (sexo, idade e profissão). Resultados: Dos 7.135 participantes inscritos no período de março a dezembro de 2018, 2.902 (40,7%) responderam aos instrumentos de pesquisa. A confiabilidade do questionário de satisfação foi boa (alfa de Cronbach = 0,83), e o curso foi bem avaliado como estratégia educacional (96,1%). Em relação ao nível de conhecimento, observou-se aumento significativo (antes = 8,10; depois = 8,74; p < 0,05) com melhoria relativa de 32%. O fator idade esteve diretamente associado à aprendizagem (β = 1,36; IC 95% = 0,35-2,36; p = 0,008). Conclusão: A utilização do MOOC mostrou-se efetiva para o ensino de segurança no processo de medicação, ferramenta que pode ser utilizada para a inserção do tema segurança do paciente nos currículos das profissões de saúde.

Abstract: Introduction: Medication errors are common and cause suffering and costs that can be prevented. The mitigation of adverse drug events is treated as a priority by the World Health Organization (WHO), which recommends including the subject of patient safety in the curricula of health profession courses to minimize harm to patients. An open and massive online course (MOOC) on safety in the medication process was developed as an educational strategy for the health area, which was made available through the SUS Virtual Learning Environment (AVASUS) in March 2018. Objective: To estimate the satisfaction and learning of the participants who finished the course. Method: Uncontrolled quasi-experimental design study. The MOOC consists of 30 hours of learning and addresses topics on safety in prescription, dispensing, administration and notification of incidents related to medications. Multiple choice questions were applied pre-and post-test to assess the participants' level of knowledge and a satisfaction survey was answered at the end of the course. The reliability of the measurement instruments, the significance of improved knowledge and associated factors (sex, age and profession) were analyzed. Results: Of the 7,135 registered participants, from March to December 2018, 2,902 (40.7%) responded to the survey instruments. The reliability of the satisfaction questionnaire was good (Cronbach's alpha = 0.83) and the course was well evaluated as an educational strategy (96.1%). Regarding the level of knowledge, a significant increase was observed (before = 8.10; after = 8.74; p <0.05) with a relative improvement of 32%. The age factor was directly associated with learning (β = 1.36; 95% CI = 0.35-2.36; p = 0.008). Conclusion: The use of MOOC proved to be effective for teaching patient safety in the medication process, a tool that can be used to insert this subject in the curricula of health profession courses.

Implementation of an improvement cycle in the care of a primary health care / Implantación de un ciclo de mejora en la acogida de una unidad básica de salud / Implantação de um ciclo de melhoria no acolhimento de uma unidade básica de saúde

ABSTRACT Objectives: to evaluate the effectiveness of a quality improvement cycle applied to the care of spontaneous demand in a primary care center. Methods: quasi-experimental before and after study, with a quantitative approach and no control group. An improvement cycle was carried out in a primary care center in the city of Guarabira/PB using five quality criteria. An evaluation, an intervention focused on the most problematic criterion and a reassessment were carried out. The samples were random (n = 60). The percentages and confidence intervals of compliance with each criterion were verified. Statistical significance was calculated using the Z test. Results: after the intervention, there was a significant improvement in two quality criteria of the care of spontaneous demand users (the user must be heard by a professional and go through the risk classification). Conclusions: the improvement cycle was an effective quality management method.

RESUMEN Objetivos: evaluar la eficacia de un ciclo de mejora aplicado a la acogida de demanda espontánea en una unidad básica de salud. Métodos: se trata de un estudio casi experimental, del tipo antes y después, sin grupo control y con enfoque cuantitativo. Se llevó a cabo un ciclo de mejoras en una unidad básica de salud de la ciudad de Guarabira, estado de Paraíba, Brasil, en el que se utilizaron cinco criterios de calidad. Se realizó una evaluación, una intervención centrada en los criterios más problemáticos y una reevaluación. Las muestras fueron aleatorias (n = 60) y se comprobaron los porcentajes e intervalos de confianza del cumplimiento de cada criterio, así como el cálculo de la significación estadística, utilizando el test Z. Resultados: después de la intervención, se produjo una mejora significativa en dos criterios de calidad de la acogida de demanda espontánea (el usuario es escuchado por algún profesional y pasa por la clasificación de riesgo). Conclusiones: la realización del ciclo de mejora se mostró eficaz como método de gestión de la calidad.

RESUMO Objetivos: avaliar a efetividade de um ciclo de melhoria aplicado ao acolhimento à demanda espontânea em uma unidade básica de saúde. Métodos: estudo quase experimental, do tipo antes e depois, sem grupo controle e com abordagem quantitativa. Realizou-se um ciclo de melhoria em uma unidade básica de saúde no município de Guarabira/PB, utilizando cinco critérios de qualidade. Foram realizadas uma avaliação, uma intervenção focada no critério mais problemático e uma reavaliação. As amostras foram aleatórias (n = 60), sendo verificados os percentuais e intervalos de confiança do cumprimento de cada critério, assim como o cálculo da significância estatística, através do teste Z. Resultados: após a intervenção realizada, houve melhoria significativa em dois critérios de qualidade do acolhimento à demanda espontânea (o usuário ser ouvido por algum profissional e passar pela classificação de risco). Conclusões: a realização do ciclo de melhoria se mostrou efetiva como método de gestão da qualidade.

Análisis de fallos y efectos en la preparación y dispensación de quimioterápicos / Failure mode and effect analysis in the preparation and dispensation of chemotherapy / Análise de falhas e efeitos na preparação e dispensação de quimioterápicos

OBJETIVO: Realizar un Análisis Multimodal de fallas y efectos para identificar prospectivamente los riesgos relacionados a la fase de la preparación y dispensación de medicamentos quimioterápicos en una unidad ambulatoria de un centro de referencia en oncología. MÉTODOS: Se utilizaron las seis primeras etapas del Análisis Multimodal de fallas y Efectos: identificar las situaciones peligrosas y montar un equipo; definir el proceso a ser analizado describiendo gráficamente; aplicar lluvia de ideas buscando identificar modos de fallas; priorizar los modos de fallas y realizar análisis de riesgos; identificar las causas potenciales de los modos de fallo y volver a dibujar el proceso. RESULTADOS: Se identificaron diecisiete modos de falla, siendo dos clasificados como de alto riesgo: cambiar la ventana de salida del medicamento y cálculo erróneo de la dosis de medicamento intratecal. CONCLUSIONES: Se identificaron los posibles modos de falla que se relacionaban al proceso analizado, además, fue posible definir causas potenciales para la existencia de esos riesgos

AIM: Conduct a Failure Mode and Effect Analysis (FMEA) to prospectively identify the risks related to the preparation and dispensation of chemotherapy drugs at an outpatient unit of a reference center in oncology. METHODS: The first six stages of Failure Mode and Effect Analysis were used to identify dangerous situations and assemble a team; define the process to be analyzed and describe it graphically; apply a host of ideas to identify failure modes; prioritize failure modes and conduct risk analysis; identify potential causes of failure modes and redesign the process. RESULTS: Seventeen failure modes were identified, two of which were classified as high risk: changing the output window for the drug and miscalculating the intrathecal drug dose. CONCLUSIONS: The possible failure modes related to the process analyzed were identified; in addition, it was possible to define potential causes of these risks

OBJETIVO: Realizar uma Análise Multimodal de Falhas e Efeitos para identificar prospectivamente os riscos relacionados à fase do preparo e dispensação de medicamentos quimioterápicos em uma unidade ambulatorial de um centro de referência em oncologia. MÉTODOS: Foram utilizadas as seis primeiras etapas da Análise Multimodal de Falhas e Efeitos: identificar as situações perigosas e montar uma equipe; definir o processo a ser analisado descrevendo graficamente; aplicar chuva de ideias buscando identificar modos de falhas; priorizar os modos de falhas e realizar análise dos riscos; identificar causas potenciais dos modos de falha e redesenhar o processo. RESULTADOS: Foram identificados dezessete modos de falha, sendo dois classificados como de alto risco: trocar a janela de saída do medicamento e cálculo errado da dose de medicamento intratecal. CONCLUSÕES: Foram identificados os possíveis modos de falha que se relacionavam ao processo analisado, além disso, foi possível definir causas potenciais para a existência desses riscos

AGRASS Questionnaire: Assessment of Risk Management in Health Care.

OBJECTIVE: This study aims to assess the development and the validity analysis of the Assessment of Risk Management in Health Care Questionnaire (AGRASS). METHODS: This is a validation study of a measurement instrument following the stages: 1) Development of conceptual model and items; 2) Formal multidisciplinary assessment; 3) Nominal group for validity analysis with national specialists; 4) Development of software and national pilot study in 62 Brazilian hospitals 5) Delphi for validity analysis with the users of the questionnaire. In stages 3 and 5, the items were judged based on face validity, content validity, and utility and viability, by a 1-7 Likert scale (cut-off point: median < 6). Accuracy and reliability of the questionnaire were analyzed with the Confirmatory Factor Analysis and the Cronbach's alpha. RESULTS: The initial version of the instrument (98 items) was adapted during stages 1 to 3 for the final version with 40 items, which were considered relevant, of adequate content, useful, and viable. The instrument has 2 dimensions and 9 subdimensions, and the items have closed-ended questions (yes or no). The software for the automatic collection and analysis generates indicators, tables, and automatic graphs for the assessed institution and aggregated data. The adjustment indices confirmed a bi-dimensional model composed of structure and process (X2/gl = 1.070, RMSEA ≤ 0.05 = 0.847, TLI = 0.972), with high reliability for the AGRASS Questionnaire (α = 0.94) and process dimension (α = 0.93), and adequate for the structural dimension (α = 0.70). CONCLUSIONS: The AGRASS Questionnaire is a potentially useful instrument for the surveillance and monitoring of the risk management and patient safety in health services.

Agrass questionnaire: Assessment of risk management in health care / Questionário agrass: Avaliação da gestão de riscos assistenciais em serviços de saúde

ABSTRACT OBJECTIVE This study aims to assess the development and the validity analysis of the Assessment of Risk Management in Health Care Questionnaire (AGRASS). METHODS This is a validation study of a measurement instrument following the stages: 1) Development of conceptual model and items; 2) Formal multidisciplinary assessment; 3) Nominal group for validity analysis with national specialists; 4) Development of software and national pilot study in 62 Brazilian hospitals 5) Delphi for validity analysis with the users of the questionnaire. In stages 3 and 5, the items were judged based on face validity, content validity, and utility and viability, by a 1-7 Likert scale (cut-off point: median < 6). Accuracy and reliability of the questionnaire were analyzed with the Confirmatory Factor Analysis and the Cronbach's alpha. RESULTS The initial version of the instrument (98 items) was adapted during stages 1 to 3 for the final version with 40 items, which were considered relevant, of adequate content, useful, and viable. The instrument has 2 dimensions and 9 subdimensions, and the items have closed-ended questions (yes or no). The software for the automatic collection and analysis generates indicators, tables, and automatic graphs for the assessed institution and aggregated data. The adjustment indices confirmed a bi-dimensional model composed of structure and process (X2/gl = 1.070, RMSEA ≤ 0.05 = 0.847, TLI = 0.972), with high reliability for the AGRASS Questionnaire (α = 0.94) and process dimension (α = 0.93), and adequate for the structural dimension (α = 0.70). CONCLUSIONS The AGRASS Questionnaire is a potentially useful instrument for the surveillance and monitoring of the risk management and patient safety in health services.

RESUMO OBJETIVO O estudo objetiva descrever a construção e análise da validade do Questionário Avaliação da Gestão de Riscos Assistenciais em Serviços de Saúde (AGRASS). MÉTODOS Trata-se de estudo de validação de um instrumento de medida nas etapas: 1. construção do modelo conceitual e itens; 2. apreciação formal multidisciplinar; 3. grupo nominal para análise da validade com especialistas da esfera nacional; 4. desenvolvimento de softwares e estudo-piloto nacional em 62 hospitais do Brasil; 5. Delphi para análise da validade com utilizadores do questionário. Nas etapas 3 e 5, os itens foram julgados quanto à validade de face e conteúdo, utilidade e viabilidade, em uma escala Likert de 1 a 7 (ponto de corte: mediana < 6). A validade de construto e a confiabilidade foram analisadas com análise fatorial confirmatória e coeficientes α de Cronbach. RESULTADOS A versão inicial do instrumento (98 itens) foi adaptada durante as etapas 1 a 3 para a versão com 40 itens considerados relevantes, de conteúdo adequado, úteis e viáveis. O instrumento tem duas dimensões e nove subdimensões, e os itens têm opção de resposta fechada (sim ou não). Os softwares para coleta e análise automática geram indicadores, tabelas e gráficos automáticos para a instituição avaliada e conjuntos agregados. Os índices de ajuste confirmaram o modelo bidimensional de estrutura e processo (X2/gl = 1,070, RMSEA ≤ 0,05 = 0,847; TLI = 0,972), havendo confiabilidade alta para o Questionário AGRASS (α = 0,94) e a dimensão processo (α = 0,93) e aceitável para a dimensão estrutura (α = 0,70). CONCLUSÃO O Questionário AGRASS é um instrumento potencialmente útil para a vigilância e monitoramento da gestão de riscos e segurança do paciente em serviços de saúde.

Gestión de calidad en el prenatal: atención a las infecciones urinarias en un municipio de la Amazonia Legal / Gestão da qualidade no pré-natal: atenção às infecções urinárias em um município da Amazônia Legal / Quality management in pre-natal care: urinary infections care in a municipality of the Legal Amazon

Objetivo: evaluar efectos del ciclo de mejora de la calidad en la prevención y manejo de las infecciones urinarias gestacionales. Método: se trata de un estudio cuantitativo, con delineamiento casi experimental, tipo antes y después, sin grupo control, realizado en Cacoal / RO, entre marzo de 2015 y febrero de 2016. Se aplicó un ciclo externo de mejora de la calidad para la prevención y manejo de las infecciones urinarias en el prenatal. Esto ocurrió con evaluaciones de cinco criterios de calidad. Resultados: la mayoría de los criterios presentaron p <0,001, excepto el criterio 1. Los criterios 1, 2 y 4 alcanzaron un porcentaje superior al 65% en los saludos. El criterio 3, a pesar de haber alcanzado el 30% de mejora absoluta, aún no alcanzó el 50% de cumplimiento. En el criterio 5, se deduce que el 10,8% de la muestra constaba de los resultados de exámenes de orina alterados, de las cuales 53% tenían registro de tratamiento adecuado. Conclusiones: la metodología empleada con el ciclo externo de la mejora de la calidad colaboró en el remodelamiento de los procesos asistenciales del prenatal, en la integración entre los equipos de trabajo, fortaleciendo la cogestión y la coparticipación de los trabajadores en los procesos de gestión. Posibilitó reflexiones acerca de los flujogramas vigentes, mejorando el acceso de las gestantes a los servicios de salud ya la calidad asistencial

Objetivo: avaliar efeitos do ciclo de melhoria da qualidade na prevenção e manejo das infecções urinárias gestacionais. Método: trata-se de um estudo quantitativo, com delineamento quase-experimental, tipo antes e depois, sem grupo controle, realizado em Cacoal/RO, entre março de 2015 e fevereiro de 2016. Aplicou-se um ciclo externo de melhoria da qualidade para a prevenção e manejo das infecções urinárias no pré-natal. Este ocorreu com avaliações de cinco critérios de qualidade. Resultados: a maioria dos critérios apresentaram p<0,001, exceto o critério 1. Os critérios 1, 2 e 4 alcançaram percentual acima de 65% nos cumprimentos. O critério 3, apesar de ter alcançado 30% de melhoria absoluta, ainda não atingiu 50% de cumprimento. No critério 5, inferiu-se que 10,8% da amostra constava os resultados de exames de urina alterados, destas 53% tinham registro de tratamento adequado. Conclusões: a metodologia empregada com o ciclo externo da melhoria da qualidade colaborou no remodelamento dos processos assistenciais do pré-natal, na integração entre as equipes de trabalho, fortalecendo a cogestão e a coparticipação dos trabalhadores nos processos de gestão. Possibilitou reflexões acerca dos fluxogramas vigentes, o que refletiu na melhoria do acesso das gestantes aos serviços de saúde e à qualidade assistencial

Objective: to evaluate the effects of a quality improvement cycle in the prevention and management of UTI during pre-natal. Methodology: this is a quantitative study with partly completed experimental design type before and after, with no control group, carried out in Cacoal/RO between March 2015 and February 2016. An external quality improvement cycle was applied for the prevention and management of pre-natal urinary infections. This occurred with evaluations of five quality criteria. Results: multi-variate analysis of quality improvement, it was observed that most of the criteria of statistical significance (p> 0.001), except criterion 1 which showed a p lower than expected. The criteria 1, 2 and 4 achieved a percentage above 65% compliance in both the samples. With respect to criterion 5, it can be inferred that 10.8% of the analyzed sample contained record examination results EQU and/or altered urine culture, and of these 53% had adequate treatment record. Conclusion: the methodology used to improve the quality of the external cycle collaborated in the remodeling of the care processes of pre-natal and especially in the integration between care teams and managers of different levels of complexity worked, strengthening co-management and co-participation of workers involved directly in care for users in the municipal health management processes. It has also enabled reflections on the existing flowcharts, providing the re-design of the same as reflected in improving access of pregnant women to health services and quality care