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Proposal to introduce and use human factors engineering technologies in Brazilian healthcare system

Grant number: 11/20383-6
Support Opportunities:Regular Research Grants
Duration: March 01, 2012 - February 28, 2014
Field of knowledge:Engineering - Biomedical Engineering
Principal Investigator:Saide Jorge Calil
Grantee:Saide Jorge Calil
Host Institution: Faculdade de Engenharia Elétrica e de Computação (FEEC). Universidade Estadual de Campinas (UNICAMP). Campinas , SP, Brazil


In the past few decades, there has been an unprecedented focus on patient safety in North America due to landmark reports highlighting the high rate of preventable adverse events. Specifically, in 1999, the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Healthcare System, concluded that between 44,000 and 98,000 people die annually in the United States due to preventable medical errors. Medication errors were said to account for 7,000 of these deaths. In 2004, a similar study of adverse events in Canadian hospitals estimated an annual rate of 9,000 to 24,000 deaths due to preventable errors, with medication (drug- or fluid-related) errors being the second leading cause of adverse events. In Brazil, the National Health Surveillance Agency (ANVISA) is the government organization that receives all adverse reports from a network of health units called "Rede Sentinela". Despite such network, there are only few isolated studies that identify adverse events involving drug infusions in Brazil but most of them focus on wrong drug or wrong dose administration but none on how to reduce the number of such events. Recent studies published by ANVISA described problems reported by its "Rede Sentinela" whete it is highlighted the high incidence of medical errors due to intravenous administration of drugs using infusion pumps.Human Factors Engineering (HFE) has a long tradition in the aviation and industrial area to study and analyze events and actions that may cause incidents during procedures. Researchers working in this area developed powerful tolls to study how human beings interact with technology in general, and how it is possible to improve its design to reduce the number of mistakes by its users. Such tolls can even analyze eventual design flaws in a device and possible future difficulties users may face when dealing with it. The Centre for eHealth Innovation (CeHI) from the University Health Network in Canada is working with HFE for about 16 years and has a highly specialized team to work with tools such as; task analysis, usability testing and heuristic analysis. The Centre already developed several works for the Ministry of Health and Long Term Care in Toronto (Canada) to improve efficiency in healthcare and reduce the number of incidents, mainly the one regarding intra venous infusion of drugs. The Centre is equipped with several laboratories where simulations of medical procedures are performed to observe the nurse's interaction with medical equipment. Presently, one of the researches they are developing is on multiple line IV pumps to analyze the interaction of nurses using these devices and report to the Ministry of Health the problems they observed on such interaction and possible actions to reduce the number of medical errors. In general terms, the proposal here is to repeat this same experiment in Brazil also using HFE tools and having the CeHI team as advisors. The expected outcome may be quite different from what they are obtaining in Canada due to different hospital environmental conditions, different training background of Brazilian nurses, different behavior to perform the IV infusion procedure and different medical equipment as well as Intravenous settings. While performing this research, the intention is to acquire the basic knowledge and training to use HFE tools to apply them on future investigations in the health area as well as to produce a report that will help ANVISA to reduce the number of adverse events. (AU)

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