Experiência na utilização do modelo Hfacs (Sistema de Análise e Classificação de Fatores Humanos) na estruturação de mapas causais de eventos adversos
DOI:
https://doi.org/10.15448/2179-703X.2017.1.27186Keywords:
Segurança do paciente, Fatores humanos, Gestão de risco.Abstract
Trata-se de um relato de experiência, cujo objetivo é descrever a utilização da ferramenta Sistema de Análise e Classificação de Fatores Humanos (HFACS) na análise de um evento sentinela, ocorrido em um hospital brasileiro público de médio porte. Buscou-se mapear os fatores humanos e classificar os fatores que contribuíram e levaram a ocorrência do dano. Vale ressaltar que a finalidade é identificar falhas no processo de trabalho, de equipamentos ou outras questões existentes, as quais possibilitam a ocorrência do erro humano, baseando-se no pensamento sistêmico.
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Experience in use of HFACS (Human Factors Analysis and Classification System) model in structuring causal maps of adverse events
Abstract: This experience report aimed to describe a tool from the Human Factors Analysis and Classification System (HFACS) used in the analysis of a sentinel event that occurred in a Brazilian medium-sized public hospital. Human factors were mapped and classified in terms of causes that contributed and led to a harmful occurrence. It is worth highlighting that the purpose is to identify flaws in the work process, equipment or other existing practices, as possible causes of human failure, based on systemic thinking.
Keywords: Patient safety; Human factors; Risk management.
References
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Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.
Oliveira JO. Apesar de desastres, viagens aéreas foram mais seguras em 2014. Disponível em: <http://www.valor.com.br/empresas/3943848/indice-de-acidentes-aereos-cai-mesmocom-tragedias-da-malaysia>. Acesso em: 22 jan. 2016.
The HFACS Framework. Disponível em: <http://www.hfacs.com/history.html>. Acesso em: 17 jan. 2015.
Sobreda SF, Soviero PADO. SERA e HFACS: Dois Sistemas para Análise e Classificação do Erro Humano em Acidentes e Incidentes Aeronáuticos. Conexão SIPAER. 2011; 3(1): 149-187.
Shappell SA, Wiegmann DA. The Human Factors Analysis and Classification System. Oklahoma: FAA Civil Aeromedical Institute; 2000.
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