Procedimento para a análise e a prevenção de erros de medicação usando o enfoque da ergonomia
DOI:
https://doi.org/10.17533/udea.rfnsp.e346223Palavras-chave:
Ergonomia, erros de medicação, segurança do paciente, erros de procedimento, sistemas de medicaçãoResumo
Os erros de medicação representam um problema de saúde pública que afeta a segurança do paciente e a qualidade dos serviços de saúde em escala global. Neste artigo apresentase um procedimento para a análise e a prevenção de erros de medicação desde a perspectiva da ergonomia, exemplificandose sua aplicação por meio de um caso de estudo ilustrativo de administração de um medicamento injetável. Como parte do procedimento exposto, incluíram-se os métodos reconhecidos Hierarchical Task Analysis (HTA) para a análise da tarefa e Systematic Human Error Reduction and Prediction Approach (SHERPA) para a identificação dos modos de erro. Para a valorização de riscos empregou-se a matriz de riscos proposta na norma ISSO 45001. O procedimento proposto ficou conformado por quatro etapas: 1) seleção da tarefa objeto de estudo, 2) análise
detalhado da tarefa, 3) predição da possibilidade de erro e 4) desenvolvimento de estratégias para redução do erro. Esperase que a utilização sistemática deste procedimento contribua na melhora da qualidade dos serviços de saúde, diminuindo os erros humanos e os possíveis eventos adversos.
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