Programa <i>Fall Tailoring Interventions for Patient Safety Brasil:</i> estudo de avaliabilidade em hospital de ensino

Medeiros, Adeli Regina Prizybicien de; Gonçalves, Luciana Schleder

doi:10.1590/0034-7167-2023-0348pt

Adeli Regina Prizybicien de Medeiros Autor Correspondente: Adeli Regina Prizybicien de Medeiros E-mail: adeli.medeiros@ufpr.br

concepção ou desenho do estudo/pesquisa

análise e/ou interpretação dos dados

revisão final com participação crítica e intelectual no manuscrito

Universidade Federal do Paraná. Curitiba, Paraná, Brasil

https://orcid.org/0000-0001-9976-8439

Luciana Schleder Gonçalves

concepção ou desenho do estudo/pesquisa

análise e/ou interpretação dos dados

revisão final com participação crítica e intelectual no manuscrito

Universidade Federal do Paraná. Curitiba, Paraná, Brasil

https://orcid.org/0000-0003-3105-3028

Autor Correspondente: Adeli Regina Prizybicien de Medeiros E-mail: adeli.medeiros@ufpr.br

EDITOR CHEFE: Antonio José de Almeida Filho

EDITOR ASSOCIADO: Ana Fátima Fernandes

Componentes do estudo de avaliabilidade(¹¹11 Leviton LC, Khan LK, Rog D, Dawkins N, Cotton D. Evaluability assessment to improve public health policies, programs, and practices. Annu Rev Public Health. 2010;31(1):213-33. https://doi.org/10.1146/annurev.publhealth.012809.103625 https://doi.org/10.1146/annurev.publheal... , ¹⁶16 Trevisan MS, Walser TM. Evaluability Assessment: improving evaluation quality and use. Califórnia: SAGE Public; 2015. 200 p.)	Objetivos	Estratégias
1. Definição do foco do EA.	Definir o foco do EA. Identificar os stakeholders do programa na instituição de saúde pesquisada.	Análise de documentos, relatórios e publicações científicas sobre segurança do paciente, prevenção de quedas e sobre o programa Fall TIPS, realizada pela pesquisadora, desenvolvida de agosto de 2021 a julho de 2023. Realização de seis reuniões com gestores da instituição, que antecederam a solicitação de indicação de stakeholders junto aos gestores de enfermagem e ao Setor de Gestão da Qualidade e Segurança do Paciente.
2. Desenvolvimento de uma teoria inicial do programa.	Construir os modelos teórico e lógico e propor indicadores para a avaliação do programa Fall TIPS Brasil.	Condução de seis oficinas(¹⁷17 Trentini M. O processo convergente assistencial. In: Trentini M, Paim L, Silva DMG. (Eds.), Pesquisa convergente assistencial: delineamento provocador de mudanças nas práticas de saúde. Porto Alegre: Moriá; 2014. p. 31-61.) pela pesquisadora e participação dos stakeholders: - Cada uma com duração de 60 minutos, realizadas de setembro a novembro de 2022. - Gravação em áudio com autorização prévia. Utilização de um planner. Contaram com a presença de observadores que fazem parte do projeto Fall TIPS Brasil.
3. Coleta de feedback sobre a teoria do programa.	Validar o modelo teórico, modelo lógico e indicadores para o programa Fall TIPS Brasil.	Condução de três oficinas para validação(¹⁷17 Trentini M. O processo convergente assistencial. In: Trentini M, Paim L, Silva DMG. (Eds.), Pesquisa convergente assistencial: delineamento provocador de mudanças nas práticas de saúde. Porto Alegre: Moriá; 2014. p. 31-61.) pela pesquisadora, duas online e uma presencial: - Cada uma com duração de 90 minutos, realizadas de junho a julho de 2023, sob a orientação da pesquisadora; - Gravação em áudio, com autorização prévia.
4. Contribuições para os usos do EA.	Sintetizar os principais resultados do estudo.	Elaboração de uma síntese sobre os usos do EA pela pesquisadora, em julho de 2023.

Questões-chave	Respostas aos pontos-chave
1 Situação problema a ser solucionada com o programa	Quedas hospitalares, frequentemente causadas por múltiplos fatores, são preveníveis em mais de 90% das situações. Na maioria das vezes, ocorrem em ambientes adjacentes ao leito e ao quarto do paciente, apesar da avaliação de risco para quedas e da recomendação de cuidados universais para sua prevenção(²⁰20 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução de Diretoria Colegiada n.36, de 25 julho de 2013. Brasília: Diário Oficial da União; 2013., ²¹21 Ministério da Saúde (BR). Portaria de Consolidação n.5, de 28 de setembro de 2017. Brasília: Diário Oficial da União; 2017., ²²22 Ministério da Saúde (BR). Portaria n. 2095, de 24 de setembro de 2017. Brasília: Diário Oficial da União, 2017., ²³23 Agência Nacional de Vigilância Sanitária (Anvisa). Protocolo de Prevenção de Quedas. Brasília: Ministério da Saúde; 2013.15p., ²⁴24 Agência Nacional de Vigilância Sanitária (Anvisa). Implantação do Núcleo de Segurança do Paciente. Brasília: Ministério da Saúde; 2013.69p., ²⁵25 Fundação Oswaldo Cruz (Fiocruz). Documento de referência para o Programa de Segurança do Paciente. Brasília: Ministério da Saúde; 2014. 42p., ²⁶26 Agência Nacional de Vigilância Sanitária (Anvisa). Assistência Segura: uma reflexão teórica aplicada à prática. Brasília: Ministério da Saúde; 2013. 168p., ²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... ).
2. Programa de saúde criado para resolver o problema	Fall TIPS adaptado ao contexto brasileiro(²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... , ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
3. Objetivo geral do programa	Prevenir quedas e seus danos, em instituições de saúde, por meio de um pôster laminado para fixação à beira leito, disponível a pacientes adultos, acompanhantes e equipes assistenciais, que possibilita o preenchimento, em conjunto, de fatores de risco individuais e sua correlação com estratégias preventivas de quedas(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
4. Objetivos específicos do programa	(4a) Proporcionar cuidado centrado no paciente com base nas experiências relacionadas à prevenção de quedas oriundas do programa(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). (4b) Contribuir para a disseminação da cultura de segurança entre profissionais, pacientes e acompanhantes(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). (4c) Facilitar a comunicação efetiva entre profissionais, pacientes e acompanhantes(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). (4d) Desenvolver habilidades e competências na equipe de saúde necessárias para prestar cuidados centrados nas pessoas(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
5. Metas a serem alcançadas pelo programa	(5a) Instituir normas, padrões e rotinas focadas na prevenção de quedas entre pacientes internados em instituições de saúde, desde o planejamento, execução, avaliação e monitoramento de intervenções preventivas personalizadas para cada paciente(²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... , ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). (5b) Desenvolver o processo de trabalho das equipes com foco no cuidado centrado no paciente(²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... , ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). (5c) Envolver o paciente/acompanhante na prevenção de quedas, desde a admissão até a alta(²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... , ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
6. Qual a população alvo do programa	Os envolvidos incluem profissionais de saúde, pacientes internados e acompanhantes(²⁰20 Agência Nacional de Vigilância Sanitária (Anvisa). Resolução de Diretoria Colegiada n.36, de 25 julho de 2013. Brasília: Diário Oficial da União; 2013., ²¹21 Ministério da Saúde (BR). Portaria de Consolidação n.5, de 28 de setembro de 2017. Brasília: Diário Oficial da União; 2017., ²²22 Ministério da Saúde (BR). Portaria n. 2095, de 24 de setembro de 2017. Brasília: Diário Oficial da União, 2017., ²³23 Agência Nacional de Vigilância Sanitária (Anvisa). Protocolo de Prevenção de Quedas. Brasília: Ministério da Saúde; 2013.15p., ²⁴24 Agência Nacional de Vigilância Sanitária (Anvisa). Implantação do Núcleo de Segurança do Paciente. Brasília: Ministério da Saúde; 2013.69p., ²⁵25 Fundação Oswaldo Cruz (Fiocruz). Documento de referência para o Programa de Segurança do Paciente. Brasília: Ministério da Saúde; 2014. 42p., ²⁶26 Agência Nacional de Vigilância Sanitária (Anvisa). Assistência Segura: uma reflexão teórica aplicada à prática. Brasília: Ministério da Saúde; 2013. 168p., ²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ²⁸28 Hermann AP, Medeiros ARP, Zanesco C, Andrade IMPG, Wolff LDG, Figueiredo KC, et al. Falls of patients admitted to a public and teaching hospital: an analysis of notifications. Rev Min Enferm. 2023;27:e-151. https://doi.org/10.35699/2316-9389.2023.38457 https://doi.org/10.35699/2316-9389.2023.... , ²⁹29 Gonçalves LS, Meira GC, Medeiros ARP, Zanesco C, Silva LS, Faria LMG, et al. Use of the empathy map in technological production to prevent hospital falls. J Health Infor; 2023;15(Esp):1-14. https://doi.org/10.59681/2175-4411.v15.iEspecial.2023.1094 https://doi.org/10.59681/2175-4411.v15.i... , ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
7. Quais as dimensões do programa	Os recursos são subdivididos em financeiros, físicos, materiais e humanos; a dimensão assistencial abrange champions, profissionais de saúde e pacientes/acompanhantes; a dimensão engajamento do paciente e do acompanhante; a educação permanente e a dimensão de gestão(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
8. Quais as atividades desenvolvidas dentro do programa	O programa envolve a avaliação do risco de quedas, a proposição e implementação de um plano de cuidados com o engajamento de pacientes, acompanhantes e profissionais de saúde em todas as suas etapas. Também inclui a gestão da mudança do processo assistencial e a cooptação e capacitação de profissionais de saúde para participarem do programa. O engajamento de pacientes e acompanhantes é essencial(²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
9. Estruturas demandadas pelo programa para que ele cumpra sua função	Os recursos necessários para o programa incluem um ambiente físico para a educação permanente de profissionais de saúde, recursos financeiros, recursos humanos, materiais e insumos necessários à sua implantação e sustentabilidade, incluindo o pôster laminado para fixação à beira do leito(³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
10. Quais os produtos que se espera obter com a realização do programa	Redução de quedas e seus danos em pacientes internados em instituições hospitalares a partir de cuidados centrados nas pessoas(²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
11. Quais resultados o programa pretende alcançar	Evolução positiva da cultura de segurança no quesito coprodução de cuidados com pacientes e acompanhantes para uma internação hospitalar livre de quedas(²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).
12. Que fatores podem influenciar no alcance dos resultados, além dos relacionados ao programa.	a) Fatores de contexto interno/político/institucional se referem aos fatores relacionados ao apoio da gestão na implementação do programa, incluindo a alocação de recursos humanos, financeiros, físicos e materiais, bem como a cultura institucional(²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ). b) Fatores de contexto externo estão ligados à organização dos sistemas de saúde, sejam eles públicos ou privados, e estão relacionados ao cenário político, econômico e aos programas de saúde do país(²⁷27 Agência Nacional de Vigilância Sanitária (Anvisa). Como posso contribuir para aumentar a segurança do paciente: orientações aos pacientes, familiares e acompanhantes. Brasília: Ministério da Saúde; 2017. 61p., ³⁰30 Schnock KO, Howard EP, Dykes PC. Fall prevention self-management among older adults: a systematic review. Am J Prev Med. 2019;56(5):747-55. https://doi.org/10.1016/j.amepre.2018.11.007 https://doi.org/10.1016/j.amepre.2018.11... , ³¹31 Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, et al. Use of a perceived efficacy tool to evaluate the Fall TIPS program. J Am Geriat Soc. 2021;69(12):3595-601. https://doi.org/10.1111/jgs.17436 https://doi.org/10.1111/jgs.17436... , ³²32 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, et al. Adoption of a patient-tailored fall prevention program in academic health systems: a qualitative study of barriers and facilitators. OBM Geriatr. 2020;4(2):119. https://doi.org/10.21926/obm.geriatr.2002119 https://doi.org/10.21926/obm.geriatr.200... , ³³33 Duckworth M, Adelman J, Belategui K, Feliciano Z, Jackson E, Khasnabish S, et al. Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: an implementation science study. J Med Internet Res. 2019;21(1):e10008. https://doi.org/10.2196/10008 https://doi.org/10.2196/10008... , ³⁴34 Fall T.I.P.S. A Patient-Centered Fall Prevention Toolkit [Internet]. Rockville: Agency for Healthcare Research and Quality; 2023[cited 2023 Aug 27]. Available from: https://www.Falltips.org/ https://www.Falltips.org/... ).

[1] Autor Correspondente: Adeli Regina Prizybicien de Medeiros E-mail: adeli.medeiros@ufpr.br

Brasil

Brasil

Programa Fall Tailoring Interventions for Patient Safety Brasil: estudo de avaliabilidade em hospital de ensino

RESUMO

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Considerações Finais: