Análise do modo e efeito da falha no processo de sondagem vesical

Abstract

Delayed Vesicular Catheterization (DVC) is an invasive, routine procedure that presents risks to patients. This study aims to analyze the potential risks in the DVC process in adults based on the Failure Mode and Effect Analysis (FMEA) method. This is an exploratory, descriptive and evaluation research carried out at the Santa Maria University Hospital, Rio Grande do Sul, Brazil. A Working Group (WG) was formed with 10 professionals (nurses, nursing technician and doctor) involved in the DVC process. The application of the FMEA was carried out between August and December 2022, through 20 meetings, totaling 40 hours. All data from the research were transcribed into an electronic database. The construction of the flowchart and description of activities was carried out through process modeling. The WG identified four subprocesses for the DVC process, being “Indications for DVC”, “DVC passing intervention”, “DVC maintenance and/or replacement” and “DVC withdrawal”. The proactive analysis of care risks related to the review of the DVC process in the adult care hospital environment highlighted 55 (100%) potential failure modes (PFMs), 92 (100%) potential failure causes (PFCs) and 40 (100 %) potential failure effects (PFEs). In the “Indications for DVC” subprocess, six (12%) PFMs, 14 (15%) PFCs and four (10%) PFEs were recorded. The subprocess “DVC passing intervention” showed the largest number of tasks, modes, causes and effects counted, with 43 (78%) PFMs, 71 (78%) PFCs and 26 (66%) PFEs. In the sub-process “Maintenance and/or replacement of DVC”, three (5%) PFMs, three (3%) PFCs and three (7%) PFEs were counted and three (7%) in the sub-process “DVC Withdrawal”, were counted three (5%) PFMs, four (4%) PFCs and seven (17%) PFEs. The PFMs stood out, respectively: “not knowing the indications for DVC”, “not having assistance during the DVC procedure”, “not fixing the foley catheter”, “not discussing the removal of the DVC among the multidisciplinary team” and “not deflating the foley catheter cuff properly.” The subprocess “Intervention to passing DVC” presented in its failure chains, high Action Priority (AP) for the main risks that need to be proactively managed. The standardized modeling of the DVC process provided flexibility in options and sequences of activities, given different care scenarios. The applicability of the FMEA method used to review the DVC process in the hospital environment strengthened the proactive analysis of risks related to a healthcare process, a topic that requires greater visibility to contribute to the safety culture at a national level. It also highlighted the strategic position of nurses to influence decisions related to the insertion, continuous use or removal of the DVC, helping to incorporate risk management related to care practice and provided the WG with the review and discussion of the care process carried out daily, increasing the perception of care risks and expanding reflection on actions to make it safer and more qualified.