A-186 Patient Safety Rite in Diagnostic Services
Authors: Dias C , Marques F A , Morales A M , Teixeira M R , Mata L S , d. Melo G , Godoi C T , Quiarato P A , Maximo A C , De Moura A P 
Published: October 2024

Background

Safety rites are well defined in hospitals, but still incipient in diagnostic services. They aim to identify near misses early, promote discussions and improvements with teams related to adverse incidents. This study presents the implementation of the Safety Rite in a large diagnostic service in Brazil, with its challenges and results.

Methods

Gemba Walk (GW), a practice of the Lean philosophy of checking operation processes, encouraging and collaborating between teams, in addition to identifying opportunities for improvement and enabling immediate decision-making. The laboratory created its own methodology called GW-MDU, which consists of a daily checklist of questions related to processes, efficiency and results. The GW begins with a visit by the leadership, or designated person, to all sectors, answering the checklist and evaluating the need for immediate actions and action plans, with registration in an application (APP). In January 2024, the Patient Quality and Safety System (SGQSP) included questions related to the WHO (World Health Organization) safety goals in the GW: 1. Did patient identification occur without complications/identification failures at all stages of the process? 2. Was there contrast extravasation? 3. Was there allergic reactions? 4. Was there an incorrect or change administration of medication or vaccine? 5. After the end of sedation(anestesia), was there a need to extend the recovery time? 6. Was there a patient fall? 7. Was there a puncture that resulted in a hematoma? 7. Was there an adverse event that required medical action? Every “No” answer to question 1 and “Yes” to questions 2 to 7, the leader must guarantee registration of the QMS, root cause analysis and action plan. After the GW, leadership conducts the Obeya Rite daily, including the Safety Rite, with analysis of the indicators and findings identified during the round.The Safety Rite methodology was tested in a Laboratory Unit where radiology and imaging diagnostic tests, hormonal tests and sample collection for clinical analysis are carried out. After the test, interviews were realized with the leaders to evaluate the application of the Rite. Improvements were implemented and later rolled out to the other Units.

Results

The Patient Safety Rite was implemented in 646 Laboratory Units, representing 35 brands of the laboratory group. From 12/20/23 to 02/15/24, 18,614 GW were carried out, of this total, for question 1, 82.7% answered “Yes”, 9% answered “No” and 8.3% answered No Applicable. For answers 2 to 7, 1.5% answered “Yes”, 48.2% answered “No” and 50.3% answered Not Applicable. A total of 40.264 incidents were opened in the QMS, 6.4% of which were related to Rite questions.

Conclusions

The rites consolidate indicators and information, allow the identification of risks and/or events proactively and help define and disseminate corrective actions and improvements in a timely manner to avoid recurrence. However, due to the high rate of “not applicable” responses, we still have challenges and opportunities in implementation, but the correctly used Safety Rite contributes to patient safety.