Análisis de Causa Raiz, Fallas y Efectos en la gestión total de la calidad pediátrica: revisión del alcance

Lima, Luciana Andrade de; Silva, Louise Constancia de Melo Alves; Dantas, Joyce Karolayne dos Santos; Lima, Maria Solange Moreira de; Dantas, Daniele Vieira; Dantas, Rodrigo Assis Neves

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Enfermagem

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Brasil

Español English

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Sumário

REVIEW • Rev. Bras. Enferm. 74 (06) • 2021 • https://doi.org/10.1590/0034-7167-2020-0954 copiar

Análisis de Causa Raiz, Fallas y Efectos en la gestión total de la calidad pediátrica: revisión del alcance

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

analizar la aplicabilidad de las herramientas Análisis de Causa Raiz y Análisis de Fallas Modales y Efectos, con el objetivo de mejorar la atención en las unidades pediátricas.

Métodos:

revisión de alcance, realizada de acuerdo con las directrices del Instituto Joanna Briggs, siguiendo la lista de verificación de los Ítems Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. La búsqueda se realizó en mayo de 2018 en 15 fuentes de datos.

Resultados:

la búsqueda totalizó 8.254 estudios. Después de utilizar los criterios de inclusión y exclusión relevantes, se incluyeron 15 artículos en la revisión. De estos, nueve fueron publicados entre 2013 y 2018, 12 utilizaron; Análisis de Fallas Modales y Efectos y 11 realizaron intervenciones para mejorar la calidad de los procesos abordados, mostrando buenos resultados post-intervención.

Consideraciones Finales:

la aplicación de las herramientas indicó cambios y mejoras significativas en los servicios que las implementaron, resultando satisfactorias para detectar oportunidades de mejora, empleando metodologías específicas para la reducción de daños en pediatría.

Descriptores:
Pediatría; Gestión de la Calidad Total; Seguridad del Paciente; Análisis de Fallas Modales y Efectos; Análisis de Causa Raíz

N°	Articles	Total score	%
1	Van Tilburg et al., 2006⁽¹⁶16 Van Tilburg CM, Leistikow IP, Rademaker CMA, Bierings MB, Dijk ATHV. Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual Saf Health Care. 2006;15(1):58-63. https://doi.org/10.1136/qshc.2005.014902 https://doi.org/10.1136/qshc.2005.014902... ⁾	20	95.23
2	Martin et al., 2017⁽¹⁷17 Martin LD, Verma EBGS, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27(6):571-80. https://doi.org/10.1111/pan.13136 https://doi.org/10.1111/pan.13136... ⁾	19	90.47
3	Daverio et al., 2015⁽¹⁸18 Daverio M, Fino G, Luca B, Zaggia C, Pettenazzo A, Parpaiola A, et al. Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children. Paediatr Anaesth. 2015;25(12):1224-7. https://doi.org/10.1111/pan.12772 https://doi.org/10.1111/pan.12772... ⁾	19	90.47
4	Rodríguez et al., 2014⁽¹⁹19 Rodríguez SM, Galindo ACS, Herce JL, Hernández MAC, Peinado II, Álvarez AC, et al. Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. Int J Technol Assess Health Care. 2014;30(2):210-7. https://doi.org/10.1017/S0266462314000051 https://doi.org/10.1017/S026646231400005... ⁾	18	85.71
5	Lago et al., 2012⁽²⁰20 Lago P, Bizzarri G, Scalzotto F, Parpaiola A, Amigoni A, Putoto G, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. BMJ Open. 2012;2(6):1-9. https://doi.org/10.1136/bmjopen-2012-001249 https://doi.org/10.1136/bmjopen-2012-001... ⁾	18	85.71
6	Berruyer et al., 2016⁽²¹21 Berruyer M, Atkinsona S, Lebela D, Bussie`res JF. Failure mode and effects analysis (FMEA) of insulin in a mother-child university-affiliated health center. Arch Pediatr. 2016;21(1):1-8. https://doi.org/10.1016/j.arcped.2015.09.033 https://doi.org/10.1016/j.arcped.2015.09... ⁾	17	80.95
7	Dehnavieh et al., 2015⁽²²22 Dehnavieh R, Ebrahimipour H, Taleghani YM, Najar AV, Hekmat SN, Esmailzdeh H. Proactive Risk Assessment of Blood Transfusion Process, in Pediatric Emergency, Using the Health Care Failure Mode and Effects Analysis (HFMEA). Glob J Health Sci. 2015;7(1):322-31. https://doi.org/10.5539/gjhs.v7n1p322 https://doi.org/10.5539/gjhs.v7n1p322... ⁾	17	80.95
8	Apkon et al., 2004⁽²³23 Apkon M, Leonard J, Probst L, DeLizi L, Vitale R. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Qual Saf Health Care. 2004;13(4):265-71. https://doi.org/10.1136/qshc.2003.007443 https://doi.org/10.1136/qshc.2003.007443... ⁾	16.5	78.57
9	Robinson et al., 2006⁽²⁴24 Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. J Comm J Qual Patient Saf. 2006;32(3):161-6. https://doi.org/10.1016/s1553-7250(06)32021-1 https://doi.org/10.1016/s1553-7250(06)32... ⁾	15.5	73.80
10	Babiker et al., 2017⁽²⁵25 Babiker A, Amer YS, Osman ME, Al-Eyadhy A, Fatani S, Mohamed S, et al. Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: an experience from the Middle East. J Eval Clin Pract. 2018;24(1):206-11. https://doi.org/10.1111/jep.12873 https://doi.org/10.1111/jep.12873... ⁾	15	71.42
11	Jayashree et al., 2017⁽²⁶26 Jayashre M, Sasidharan R, Singhi S, Nallasamy K, Baalaaji M. Root cause analysis of diabetic ketoacidosis admissions at a tertiary referral pediatric emergency department in North India. Indian J Endocrinol Metab. 2017;21(5):710-4. https://doi.org/10.4103/ijem.IJEM_178_17 https://doi.org/10.4103/ijem.IJEM_178_17... ⁾	14.5	69.04
12	Bonnabryet al., 2005⁽²⁷27 Bonnabry P, Cingria L, Sadeghipour F, Ing H, Christ CF, Pfister RE. Use of a systematic risk analysis method to improve safety in the production of pediatric parenteral nutrition solutions. Qual Saf Health Care. 2005;14(2):93-8. https://doi.org/10.1136/qshc.2003.007914 https://doi.org/10.1136/qshc.2003.007914... ⁾	13.5	64.28
13	Morse et al., 2011⁽²⁸28 Morse RB, Pollack MM. Root cause analyses performed in a children's hospital: events, action plan strength, and implementation rates. J Healthc Qual. 2012;34(1):55-61. https://doi.org/10.1111/j.1945-1474.2011.00140.x https://doi.org/10.1111/j.1945-1474.2011... ⁾	13.5	64.28
14	Tija et al., 2014⁽²⁹29 Tjia I, Rampersad S, Varughese A, Heitmiller E, Tyler DC, Lee AC, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-36. https://doi.org/10.1213/ANE.0000000000000266 https://doi.org/10.1213/ANE.000000000000... ⁾	13	61.90
15	Bhalla et al., 2012⁽³⁰30 Bhalla T, Dairo OO, Martin D, Wrona S, Fetzer M, Taghon T, et al. A proactive risk assessment by utilizing ‘Healthcare Failure Mode and Effect Analysis’ (HFMEA) for safe implementation of peripheral nerve catheters in pediatric patients. APIC. 2014;18(1):21-4. https://doi.org/10.1016/j.jpain.2012.01.282 https://doi.org/10.1016/j.jpain.2012.01.... ⁾	13	61.90

N°	AUTHOR/YEAR	COUNTRY	PEDIATRIC UNIT TYPE	TOOL AND REFERENCE	OBJECTIVE	METHODOLOGICAL TOOL PATH	INTERVENTIONS CARRIED OUT	IMPROVEMENT INDICATORS
1	Van Tilburg et al., 2006⁽¹⁶16 Van Tilburg CM, Leistikow IP, Rademaker CMA, Bierings MB, Dijk ATHV. Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual Saf Health Care. 2006;15(1):58-63. https://doi.org/10.1136/qshc.2005.014902 https://doi.org/10.1136/qshc.2005.014902... ⁾	Netherlands	Pediatric Oncology Unit	FMEA DeRosier et al., 2002⁽³¹31 Agência Nacional de Vigilância Sanitária - ANVISA. Gestão de riscos e investigação de eventos adversos relacionados à assistência à Saúde. Série Segurança do paciente e qualidade em serviços de saúde [Internet]. Brasília: ANVISA , 2017 [cited 2018 Jul 02]. 92p. Available from: https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/caderno-7-gestao-de-riscos-e-investigacao-de-eventos-adversos-relacionados-a-assistencia-a-saude https://www20.anvisa.gov.br/segurancadop... ⁾	Investigate whether HFMEA is valid for analyzing health care processes, such as chemotherapy administration in a pediatric oncological hospitalization environment.	1Team assembly; 2. Flow diagram; 3. Risk analysis; 4. Actions of the process results.	1. Changes in treatment schedules; 2. Chemotherapy schedules; 3. Determine the minimum number of residents; 4. Prescription of chemotherapy requests by residents.	1. Professionals' satisfaction about utility, expectations, time planning, participation of parents/patients.
2	Martin et al., 2017⁽¹⁷17 Martin LD, Verma EBGS, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27(6):571-80. https://doi.org/10.1111/pan.13136 https://doi.org/10.1111/pan.13136... ⁾	USA	Children's academic hospital	FMEA Chang et al., 2012⁽³²32 Yamamoto MS, Peterlink MAS, Bohomol E. Spontaneous reporting of medication errors in pediatric university hospital. Acta Paul Enferm. 2011;24(6):766-71. https://doi.org/10.1590/S0103-21002011000600006 https://doi.org/10.1590/S0103-2100201100... ⁾	Analyze FMEA in the practice of medication performed in the operating room of a children's hospital, assessing each stage of the treatment process, scoring possible failures and risks.	1. Team set-up; 2. Flow definition; 3. Determination of "failure modes"; 4. Risk priority number (RPN) of failures 5. Interventions for those with the highest RPN.	1. Reorganization of the medication tray; 2. Top model of medication cart; 3. Syringe labelling; 4. Double infusion check; 5. Medication practice guideline.	Use of charts with failure scores and effects before and after the applied interventions.
3	Daverio et al., 2015⁽¹⁸18 Daverio M, Fino G, Luca B, Zaggia C, Pettenazzo A, Parpaiola A, et al. Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children. Paediatr Anaesth. 2015;25(12):1224-7. https://doi.org/10.1111/pan.12772 https://doi.org/10.1111/pan.12772... ⁾	Italy	PICU	FMEA Reference not mentioned	Describe the tendency of CI in PICU over a period of 4 years and assess the effect of FMEA application on the tendency and severity of medical errors.	1. Process selection; 2. Team selection; 3. Design of the process 4. Failure and effect identification; 5. Numeric value to identify weaknesses; 6. Improvement strategies.	Not performed.	1. 165% increase in report production; 2. Decrease in the severity of errors.
4	Rodríguez et al., 2014⁽¹⁹19 Rodríguez SM, Galindo ACS, Herce JL, Hernández MAC, Peinado II, Álvarez AC, et al. Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. Int J Technol Assess Health Care. 2014;30(2):210-7. https://doi.org/10.1017/S0266462314000051 https://doi.org/10.1017/S026646231400005... ⁾	Spain	PICU	FMEA Joint Commission on Accreditation of Healthcare Organizations⁽³³33 World Health Organization (WHO). Conceptual framework for the international classification for patient safety [Internet]. Geneva; 2009 [cited 2018 Jul 01]. Available from: https://www.who.int/patientsafety/taxonomy/icps_full_report.pdf https://www.who.int/patientsafety/taxono... ⁾	Carry out FMEA on the risks in the use of intelligent infusion pumps in PICU before and after the implementation of the devices to identify improvement actions.	1. Team assembling; 2. Identify risks at different stages; 3. Qualitative analysis of failure cause and effect; 4. Quantitative analysis for each error; 5. Actions to minimize the probability of occurrence.	Conducting periodic reviews of the medicines library, developing supporting documents and including training. After 18 months, smart pump technology was introduced into PICU.	Use of the GuardrailsR CQI v4.1 Event Reporter Software
5	Lago et al., 2012⁽²⁰20 Lago P, Bizzarri G, Scalzotto F, Parpaiola A, Amigoni A, Putoto G, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. BMJ Open. 2012;2(6):1-9. https://doi.org/10.1136/bmjopen-2012-001249 https://doi.org/10.1136/bmjopen-2012-001... ⁾	Italy	Pediatric hospital	FMEA Reference is not mentioned.	Examine the dangers associated with the drug delivery process to children by conducting a proactive risk assessment analysis.	1. Team set-up; 2. Flow diagrams; 3. Highlight possible sources of errors; 4. Reason for failure; 5. Quantify the severity of the effects; 6. Risk reduction strategy.	1. Preprint label for patient identification; new way of reordering medicines; quiet place to prepare recipes; active ingredient prescription; prescription with understandable writing; 2. Clinical audits.	RPN values before and after interventions.
6	Berruyer et al., 2016⁽²¹21 Berruyer M, Atkinsona S, Lebela D, Bussie`res JF. Failure mode and effects analysis (FMEA) of insulin in a mother-child university-affiliated health center. Arch Pediatr. 2016;21(1):1-8. https://doi.org/10.1016/j.arcped.2015.09.033 https://doi.org/10.1016/j.arcped.2015.09... ⁾	Canada	Installation of parents and children of the University Hospital of Montreal	FMEA Institute of Safe Medication Practices⁽³⁴34 Predebon CM, Silva SC, Olaves FS, Kantorski KJC, Pedro ENR, Wegner W. Perfil das notificações de incidentes analisados pela comissão de qualidade e segurança pediátrica. In: ANAIS - I Congresso Internacional da Rebraensp [Internet]. 2016 [cited 2019 Nov 04]. Available from: https://www.lume.ufrgs.br/bitstream/handle/10183/140646/000991213. pdf?sequence=1 https://www.lume.ufrgs.br/bitstream/hand... ⁾	Assess the risks associated with insulin use in a health unit and propose an action plan to reduce the main risks associated with failures.	1. Classification of the failure mode grid by a team; 2. Calculation of criticality indexes; 3. Approval of classifications; 4. Data analysis.	1. Audit; 2. Update service appropriations with insulin; 3. Reassessment of dispensation policy; 5. Raise caregivers' awareness.	Assessment of criticality indexes.
7	Dehnavieh et al., 2015⁽²²22 Dehnavieh R, Ebrahimipour H, Taleghani YM, Najar AV, Hekmat SN, Esmailzdeh H. Proactive Risk Assessment of Blood Transfusion Process, in Pediatric Emergency, Using the Health Care Failure Mode and Effects Analysis (HFMEA). Glob J Health Sci. 2015;7(1):322-31. https://doi.org/10.5539/gjhs.v7n1p322 https://doi.org/10.5539/gjhs.v7n1p322... ⁾	Iran	Pediatric Emergency Department	FMEA (HFMEA) Cheng et al, 2012⁽³⁵35 Najar AV, Ghane H, Ebrahimipour H, Nouri GA, Dadpour B. Identification of priorities for medication safety in the neonatal intensive care unit via failure mode and effect analysis. Iranian J Neonatol[Internet]. 2016 [cited 2020 Aug 12];7(2):28-34. Available from: http://ijn.mums.ac.ir/article_7113.html http://ijn.mums.ac.ir/article_7113.html... ⁾	Assess the risk in the blood transfusion process in a pediatric emergency through the FMEA tool.	1. Team meeting; 2. Flow diagram 3. Harm analysis in 04 phases; 4. Measure of action; 4.1. Action description; 4.2. Process redesign.	Not performed.	Not mentioned.
8	Apkon et al., 2004⁽²³23 Apkon M, Leonard J, Probst L, DeLizi L, Vitale R. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Qual Saf Health Care. 2004;13(4):265-71. https://doi.org/10.1136/qshc.2003.007443 https://doi.org/10.1136/qshc.2003.007443... ⁾	USA	PICU	FMEA Grissinger et al., 2002⁽³⁶36 DeRosier J, Stalhandske E, Bagian JP, Tina NMS. Using health care failure mode and effect analysis: the VA National Center for Patient Safety’s prospective risk analysis system. J Comm Qual Improv. 2002;28(5):248-67. https://doi.org/10.1016/S1070-3241(02)28025-6 https://doi.org/10.1016/S1070-3241(02)28... ⁾ (Joint Commission on Accreditation of Healthcare Organizations)	Administer continuous infusions, improving patient safety, team, hemodynamic stability during infusion and efficient use of resources.	1. Characterize process steps; 2. Identify failure modes; 3. RPN calculation; 5. Corrective measures for elements with the highest RPN.	1. Standard formulations; 2. Calculators for multiple computing platforms; 4. Prefabricated purchase and stock; 5. Change the responsibility for the pharmacy preparation.	1. Team satisfaction; 2. RPN assessment, severity (S), occurrence (O) and detection (D) values before and after corrective measures.
9	Robinson et al., 2006⁽²⁴24 Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. J Comm J Qual Patient Saf. 2006;32(3):161-6. https://doi.org/10.1016/s1553-7250(06)32021-1 https://doi.org/10.1016/s1553-7250(06)32... ⁾	USA	Pediatric Oncology Unit	FMEA (HFMEA) Adachi W, Lodolce A, 2005⁽³⁷37 Joint Commission Resources. Joint Commission International. Root Cause Analysis in Health Care: Tools and Techniques. 5. ed. Oak Brook: The Joint Commission; 2015.⁾	Use FMEA to identify appropriate risks and strategies in the administration of chemotherapy in children.	1. Data collection; 3. Flowchart; 4. Failure points and the cause. 5. Identify the cause; 6. Strategies to reduce risks.	The team made and implemented the recommendations in the process of medication prescription and administration.	Comparison of the percentages of prescription error, medication dispensing and administration.
10	Babiker et al., 2017⁽²⁵25 Babiker A, Amer YS, Osman ME, Al-Eyadhy A, Fatani S, Mohamed S, et al. Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: an experience from the Middle East. J Eval Clin Pract. 2018;24(1):206-11. https://doi.org/10.1111/jep.12873 https://doi.org/10.1111/jep.12873... ⁾	Saudi Arabia	Department of Pediatrics, King Khalid University Hospital	FMEA IHI Workspace online⁽³⁸38 Ceccim RB. Permanent health education: decentralization and dissemination of pedagogical capacity in health. Ciênc Saúde Colet. 2005;10(4):975-86. https://doi.org/10.1590/S1413-81232005000400020 https://doi.org/10.1590/S1413-8123200500... ⁾	Provide an accurate assessment of the occurrence and frequency of failures and their effects on clinical practice.	1. Team assembling; 2. Training on FMEA; 3. Data collection; 4. Identification of potential failures; 5. Score for each attribute item; 6. The number of risk priorities was calculated.	1. Regular audit; 2. Improvement of Clinical Practice Guidelines (CPG); 3. Quality improvement; 4. Organization of awareness-raising activities; 5. Availability of printed or electronic materials;	1. Number of adapted CPGs finalized; 2. Number of general awareness-raising sessions; 3. Number of educational sessions; 4. Percentage of patients who achieved the results.
11	Jayashree et al., 2017⁽²⁶26 Jayashre M, Sasidharan R, Singhi S, Nallasamy K, Baalaaji M. Root cause analysis of diabetic ketoacidosis admissions at a tertiary referral pediatric emergency department in North India. Indian J Endocrinol Metab. 2017;21(5):710-4. https://doi.org/10.4103/ijem.IJEM_178_17 https://doi.org/10.4103/ijem.IJEM_178_17... ⁾	India	Emergency department	RCA Iedema et al., 2006⁽³⁹39 Hamilton MJ, MCEniery JA, Osborne JM, Coulthard MG. Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014. J Paediatr Child Health. 2019;55(9):1070-6. https://doi.org/10.1111/jpc.14344 https://doi.org/10.1111/jpc.14344... ⁾	Identify factors contributing to admissions to the Emergency Department (ED) of children with diabetic ketoacidosis, with emphasis on awareness of parents, the doctor and prenatal management.	1. Theme discussion; 2. Questionnaire formulation; 3. Preparation of a causal factor diagram; 4. Identification of complications, their causes and effects; 5. Use of descriptive statistics of the data found.	Not performed.	Not mentioned.
12	Bonnabry et al., 2005⁽²⁷27 Bonnabry P, Cingria L, Sadeghipour F, Ing H, Christ CF, Pfister RE. Use of a systematic risk analysis method to improve safety in the production of pediatric parenteral nutrition solutions. Qual Saf Health Care. 2005;14(2):93-8. https://doi.org/10.1136/qshc.2003.007914 https://doi.org/10.1136/qshc.2003.007914... ⁾	Switzerland	Pediatric hospital	FMEA McDonough, 2003⁽⁴⁰40 Ricaldoni CAC, Sena RR. Permanent education: a tool to think and act in nursing work. Rev Latino Am Enferm. 2006;14(6):837-42. https://doi.org/10.1590/S0104-11692006000600002 https://doi.org/10.1590/S0104-1169200600... ⁾	Compare the risks associated with old and new processes to quantify improved safety with the new process and identify risks to improve safety in the production of pediatric parenteral nutrition solutions.	1. Team assembling; 2. Definition of process stages; 3. Brainstorming; 4. Cause-effect diagram; 5. Comparison of the two methods	Implementation of integrated access software, in order to guide the prescribing physician and connect the prescription process directly to the production process, including pharmaceutical validation, labeling and composition.	The sum of CIs from all 18 identified failure modes was 3,415 for the old process and 1,397 for the new one (59% reduction).
13	Morse et al., 2011⁽²⁸28 Morse RB, Pollack MM. Root cause analyses performed in a children's hospital: events, action plan strength, and implementation rates. J Healthc Qual. 2012;34(1):55-61. https://doi.org/10.1111/j.1945-1474.2011.00140.x https://doi.org/10.1111/j.1945-1474.2011... ⁾	USA	Pediatric hospital	RCA The Joint Commission, 2009⁽⁴¹⁾	Establish a reference point to monitor the strength of action plans developed through RCA and its execution rates.	1. Each RCA was analyzed by the Director of the Quality Department; 2. Actions developed to address each individual event were classified as weak, intermediate or strong, using the recommended hierarchy of actions.	1. Improvement in documentation and communication; 2. Software improvement in the entry of computerized requests; 3. Reduce distractions; 4. Standardize processes; 5. Continued training; 6. Analyze and inspect equipment.	Comparison of the implementation of the actions developed as a result of RCAs with previous studies.
14	Tjiaet al., 2014⁽²⁹29 Tjia I, Rampersad S, Varughese A, Heitmiller E, Tyler DC, Lee AC, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-36. https://doi.org/10.1213/ANE.0000000000000266 https://doi.org/10.1213/ANE.000000000000... ⁾	USA	Pediatric hospital	FMEA Reference is not mentioned.	Implement changes in care processes that improve the quality and safety of anesthetic care provided to pediatric patients throughout the country.	1. Questions to analyze and identify system failures; 2. Team members; 3. Recommendations; 4. Action plan follow up.	Not performed.	Not mentioned.
15	Bhalla et al., 2012⁽³⁰30 Bhalla T, Dairo OO, Martin D, Wrona S, Fetzer M, Taghon T, et al. A proactive risk assessment by utilizing ‘Healthcare Failure Mode and Effect Analysis’ (HFMEA) for safe implementation of peripheral nerve catheters in pediatric patients. APIC. 2014;18(1):21-4. https://doi.org/10.1016/j.jpain.2012.01.282 https://doi.org/10.1016/j.jpain.2012.01.... ⁾	USA	Department of Anesthesiology of Nationwide Children's Hospital	FMEA (HFMEA) Reference is not mentioned	Identify failure modes and their causes and effects on the use of peripheral catheters.	1. Multidisciplinary team assembling; 2. Follow-up meetings and interrogations; 3. Describe the process using process flow maps; 4. Identify potential failure modes related to each step of the process.	1. Home-going instructions; 2. Design of new labels for pain pump and piping; 3. Design of an electronic order-set; 4. Changes to pharmacy code kits, as well as the modification of hand-offs between services.	Not mentioned.

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[1] Corresponding author: Rodrigo Assis Neves Dantas E-mail: rodrigoenf@yahoo.com.br