Programa Fall Tailoring Interventions for Patient Safety Brasil: estudio de evaluabilidad en hospital de enseñanza

Medeiros, Adeli Regina Prizybicien de; Gonçalves, Luciana Schleder

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Enfermagem

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

ORIGINAL ARTICLE • Rev. Bras. Enferm. 77 (2) • 2024 • https://doi.org/10.1590/0034-7167-2023-0348 copiar

Programa Fall Tailoring Interventions for Patient Safety Brasil: estudio de evaluabilidad en hospital de enseñanza

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

presentar el modelo teórico, modelo lógico y matriz de análisis y juicio del programa Fall TIPS Brasil.

Métodos:

investigación cualitativa, participativa tipo estudio de evaluabilidad, que abarca las fases (1) análisis del problema; (2) diseño, desarrollo y adaptación del programa a la realidad brasileña; (3) difusión del programa. Los datos se recopilaron mediante análisis documental y talleres.

Resultados:

a través del análisis documental, talleres con partes interesadas de la institución participante y validación con informantes clave, se pudieron identificar los objetivos del programa, los resultados esperados y el público beneficiario, construir los modelos teórico y lógico y, a través de preguntas evaluativas, señalar indicadores para la evaluación del programa Fall TIPS Brasil.

Consideraciones Finales:

el estudio aportó conocimientos sobre el programa Fall TIPS, sobre la temática de prevención de caídas en hospitales, y los modelos e indicadores propuestos pueden ser utilizados en la implementación y en futuros procesos de evaluación del programa.

Descriptores:
Evaluación de Programas y Proyectos de Salud; Seguridad del Paciente; Accidentes por Caídas; Hospitales de Enseñanza; Ciencia de la Implementación

Components of the Evaluability Study(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.)	Objectives	Strategies
1. Definition of the ES’s focus.	Define the focus of the ES.	Analysis of documents, reports, and scientific publications on patient safety, fall prevention, and the Fall TIPS program, conducted by the researcher, from August 2021 to July 2023. Conducting six meetings with institution managers, preceding the request for the identification of stakeholders from the nursing managers and the Quality and Patient Safety Management Department.
2. Development of an initial program theory.	Identify the stakeholders of the program in the researched healthcare institution.	Conducting six workshops(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.) by the researcher with the participation of stakeholders: Each lasting 60 minutes, held from September to November 2022. Audio recording with prior authorization. Utilization of a planner. Included the presence of observers who are part of the Fall TIPS Brazil project.
3. Gathering feedback on the program theory.	Construct the theoretical and logical models and propose indicators for the evaluation of the Fall TIPS Brazil program.	Conducting three validation workshops(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.) by the researcher, two online and one in-person: Each lasting 90 minutes, held from June to July 2023, under the researcher’s guidance. Audio recording with prior authorization.
4. Contributions to the uses of the ES.	4Validate the theoretical model, logical model, and indicators for the Fall TIPS Brazil program.	Preparation of a synthesis on the uses of the ES by the researcher in July 2023.

Key Questions	Responses to Key Questions
1. Problem situation to be addressed by the program	Hospital falls, often caused by multiple factors, are preventable in over 90% of cases. Most of the time, they occur in areas adjacent to the patient’s bed and room, despite fall risk assessment and recommendations for universal prevention care(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. Healthcare program created to solve the problem	Fall TIPS adapted to the Brazilian context(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. Overall goal of the program	To prevent falls and their associated harm in healthcare institutions through a laminated poster for bedside placement, available to adult patients, caregivers, and healthcare teams. This poster allows for the collaborative identification of individual risk factors and their correlation with fall prevention strategies(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. Specific objectives of the program	4a. To provide patient-centered care based on experiences related to fall prevention from the program(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. To contribute to the dissemination of a safety culture among professionals, patients, and caregivers(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. To facilitate effective communication among professionals, patients, and caregivers(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. To develop skills and competencies in the healthcare team necessary for providing patient-centered care(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. Goals to be achieved by the program.	(5a) Establish norms, standards, and routines focused on fall prevention among hospitalized patients in healthcare institutions, from the planning, execution, evaluation, and monitoring of personalized preventive interventions for each patient(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) Develop the work process of healthcare teams with a focus on patient-centered care(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) Involve the patient/caregiver in fall prevention, from admission to discharge(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. The target population of the program.	The stakeholders include healthcare professionals, hospitalized patients, and caregivers(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. The dimensions of the program.	Resources are subdivided into financial, physical, material, and human resources; the care dimension encompasses champions, healthcare professionals, and patients/caregivers; the patient and caregiver engagement dimension; continuous education; and the management dimension(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. The activities carried out within the program.	The program involves fall risk assessment, the proposal and implementation of a care plan with the engagement of patients, caregivers, and healthcare professionals at all stages. It also includes the management of the change in the care process and the recruitment and training of healthcare professionals to participate in the program. Patient and caregiver engagement is essential(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. Structures required by the program to fulfill its function.	The resources required for the program include a physical environment for the continuous education of healthcare professionals, financial resources, human resources, materials, and supplies needed for its implementation and sustainability, including the laminated poster for bedside placement(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. The expected products to be obtained through the program’s implementation.	Reduction in falls and their associated harm in hospitalized patients through person-centered care(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. The results the program aims to achieve.	Positive evolution of the safety culture regarding co-production of care with patients and caregivers for a hospitalization free of falls(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. Factors that may influence the achievement of results, beyond those directly related to the program.	a) Factors of internal/political/institutional context refer to factors related to management support in implementing the program, including the allocation of human, financial, physical, and material resources, as well as institutional culture(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) Factors of external context are related to the organization of healthcare systems, whether public or private, and are linked to the political, economic, and healthcare programs’ landscape of the country(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/... ).

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

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