PROACTIVE RISK MANAGEMENT APPLIED TO THE ANTI-INFECTIVE AGENTS DISPENSING PROCESS

Abstract

Objective: To analyze the proactive risk management of the anti-infective dispensing process for an Intensive Care Unit. Method: Qualitative study, in action research, with participant observation and focus group. The process was mapped, risks analyzed, improvement actions planned and the process redesigned. Results: The dispensation occurred in an electronic system and the justifications in an electronic form. The anti-infective dispensing process had 67 activities, three sub-processes, 31 failure modes and 20 potential causes. The failure modes were delay and errors in dose, presentation and concentration, and the identified causes were human error in visually checking the medication and systemic failure due to staff deficit. Five specialists redesigned the process resulting in changes in activities and in the system. Conclusion: Proactive risk management applied to the anti-infective dispensing process was effective in identifying risks, their causes and prioritizing improvement actions.