Errar é humano – mas assumir a responsabilidade pelo erro também

Dra. Aline Yuri Chibana, presidente da Fundação para Segurança do Paciente e responsável pela Qualidade do Departamento de Anestesiologia do Hospital A. C. Camargo Cancer Center, em São Paulo

Assista a essa palestra completa em nosso canal no YouTube

O profissional de saúde do futuro deverá saber trabalhar em equipe, se comunicar e assumir a responsabilidade por seus atos, afirmou a médica anestesista Dra. Aline Chibana, responsável pela Qualidade do Departamento de Anestesiologia do Hospital A. C. Camargo Cancer Center, em São Paulo, na palestra “Anestesistas versus Cirurgiões: Evitando Mortes Evitáveis em Pacientes Cirúrgicos”, no 8º AnestEdu. “Isso inclui admitir que somos humanos propensos a falhas e, portanto, que precisamos assumir a responsabilidade de adotar protocolos de segurança por entendermos que são mecanismos de proteção importantes. Não é função da enfermagem, do médico anestesista, do cirurgião, é função de todos.”

Segundo ela, é preciso que o profissional de saúde compreenda que se o sistema de saúde não é seguro, não é seguro para ninguém. “O que se espera de nós é o chamado medical professionalism: habilidades não técnicas, reponsabilidade, entrega de valor, experiência do paciente. Somos prestadores de serviço.”

Ela explicou segurança do paciente como a jornada do paciente: o paciente procura um serviço de saúde porque tem um problema, ou seja, vai a um hospital, laboratório, clínica, consultório, etc. porque precisa de uma solução, e então passa por uma jornada completa. O objetivo é que ele termine a jornada melhor do que começou, sem que o sistema lhe acrescente mais problemas. “Segurança do paciente é proporcionarmos ao paciente essa jornada completa, resolvendo o problema que o trouxe até nós, sem adicionarmos problemas extras, que são justamente as complicações evitáveis”, definiu a Dra. Aline Chibana.

O sistema de saúde tem barreiras de proteção, mas todas elas têm falhas latentes: “Falhas próprias e falhas porque nós, os humanos, pulamos essas barreiras”. Assim, quando as falhas se alinham, vai-se do risco ao dano. “É muito importante entendermos isso porque somos humanos, vamos continuar errando porque somos humanos, e portanto, o sistema tem que ser à prova de humanos e seus erros. Como o Dr. Manara disse [na palestra ‘Rotinas e Protocolos para Acreditação: Elaboração, Implantação e Otimização de Resultados com Renovação Periódica’] ninguém sai de casa para o trabalho com o objetivo de errar. Mas é muito difícil profissional de saúde aderir e querer trabalhar em equipe, e isso é uma habilidade não técnica básica.”

A Dra. Aline Chibana falou da Fundação para Segurança do Paciente (FSP), da qual é presidente, uma organização sem fins lucrativos formada por pessoas de diversas áreas que querem colaborar tornando o sistema de saúde mais seguro. Segundo ela, os profissionais de saúde devem explicar a todas as pessoas o que é segurança do paciente, o risco que elas correm no sistema de saúde e o que devem fazer para se proteger. “Para isso foi criada a FSP, para levar informação para todo mundo, não só para profissionais de saúde, porque primeiro, pessoas corretamente informadas também poderão ser barreiras de segurança dentro do sistema de saúde. E segundo, porque a partir do momento em que abrimos a grande problemática em que estamos presos e alertamos a todos, as pessoas começam a vir e a colaborar. E as grandes soluções nem sempre vêm da área da saúde”.

Um exemplo é o robô Laura, criado pelo analista de sistemas Jacson Fressato, que se diz um hacker. Ele desenvolveu o robô, com um algoritmo para a detecção precoce de sepse, após a filha dele, Laura, morrer em decorrência de infecção generalizada. “Quem deve saber mais sobre sepse?”, perguntou a Dra. Aline Chibana. “O profissional de saúde, o familiar acompanhante ou o paciente? Quem vai fazer o reconhecimento precoce, se nas nossas enfermarias o sinal vital é feito de seis em seis horas? Se o paciente entrar em sepse logo depois que o profissional passar, o diagnóstico, com sorte, só vai ser feito dali a seis horas. Não é melhor, então, o paciente e o acompanhante estarem informados para, ao desconfiar de algum sinal, avisar alguém? O Jacson Fressato não é profissional de saúde, mas trouxe uma solução para o sistema de saúde.”

Outro exemplo é o Emma Watch, relógio desenvolvido pela Microsoft, que ajuda a reduzir tremores das mãos de pessoa com Parkinson. “Isso é colaboração, porque estamos todos presos no mesmo barco. Então não é anestesistas versus cirurgiões, é anestesistas e cirurgiões, e enfermagem, e gestores, e pacientes, e familiares, e todo mundo”, afirmou a Dra. Aline Chibana.

Errar é humano – mas encontrar a pessoa morta na cama do hospital é imperdoável

A Dra. Aline Yuri Chibana contou que entendeu de fato o que é cultura de segurança e por que todos precisam prestar atenção nela, ou seja, porque todos fazem parte dela, quando participou, em 2014, do congresso do Patient Safety Movement (do qual vem a FSP), uma instituição norte-americana que tem o objetivo de zerar o número de mortes evitáveis até 2020. E ela afirma que só entendeu de fato naquele momento apesar de já estar havia três anos formada e ativa como médica anestesista.

Todos anos, o congresso do Patient Safety Movement é aberto pelo ex-presidente dos Estados Unidos Bill Clinton. Qualquer pessoa pode participar, não apenas profissionais de saúde, inclusive pacientes e familiares de pacientes. No primeiro dia do congresso, no jantar, a Dra. Aline Chibana conheceu a mãe de uma menina que morreu por um erro médico. “Lenore Alexander se sentou ao meu lado e me contou a história dela, e isso foi o divisor de águas para mim”, contou a Dra. Aline Chibana, que acrescentou que sempre se emociona ao se recordar desse relato.

Assista ao relato de Lenore Alexander

A filha de Lenore Alexander, Leah, uma menina por volta dos 12 anos, tinha uma condição chamada “peito de pombo”, Pectus carinatum, que a deixava muito desconfortável. O médico disse que poderiam fazer algo a respeito, mas não explicou que seria uma cirurgia de grande porte. A cirurgia foi feita e, já no quarto do hospital, Leah ainda com a peridural, continuaram aumentando as doses de analgésicos opiodes, mas ela continuava com dor. O marido de Lenore e pai de Leah disse a uma enfermeira: “Eu não quero interferir no trabalho de ninguém, mas minha filha está recebendo medicação demais, e não quero que ninguém dê mais nenhuma medicação para ela”.

Então um residente disse a ele: “Se você não vai deixar que eu dê mais opioides para ela, vou ter que dar algo para a ansiedade, porque ela precisa respirar profundamente e provavelmente está só com medo de sentir dor”.

Lenore descobriu que o residente prescreveu 2 mg de um sedativo para Leah, a cada duas horas – uma droga e uma dose que, segundo Lenore, colocaria um homem adulto para dormir. “Ela nunca mais falou depois da primeira injeção”, disse Lenore.

A mãe de Leah conta que a menina não estava monitorizada, embora, segundo Lenore, a lei, nos Estados Unidos, diga que a cada duas ou quatro horas é necessário fazer a monitorização e checar os sinais vitais do paciente. Enquanto isso, Lenore, acordada havia trinta horas, cochilou por volta da meia-noite e, quando acordou, duas horas depois, percebeu que a filha estava morta. “Isso poderia ter sido evitado”, diz Lenore. “Se ela estivesse sendo monitorizada, teriam detectado que a respiração dela estava decaindo (dessaturando) e que a dose de sedativos estava muito alta. Algo os teria alertado antes de ela morrer, enquanto eu estava dormindo. E a monitorização é tão fácil atualmente, as novas tecnologias são tão simples. Não são caras e não são invasivas. Encontrar a pessoa morta na cama é imperdoável.”

Lenore reúne esforços para que seja aprovada a Lei Leah, para que a monitorização de pacientes em uso de opioides no pós-operatório seja obrigatória. “Você não deve enterrar um filho. Principalmente um filho saudável. Se você estiver em um hospital, exija um monitor.”

A Dra. Aline Chibana disse: “É isso que acontece quando um erro ocorre dentro dos nossos hospitais, nós detonamos com um núcleo familiar”. E acrescentou que foi quando Lenore lhe contou sua história, naquele congresso, que entendeu o impacto de um erro médico. “Se não conseguirmos trabalhar as habilidades não técnicas, que é o fato de sermos humanos, não poderemos entregar um serviço de excelência, seguro. Erro médico é a terceira causa de morte no mundo”, afirmou.

Errar é humano – mas é preciso saber trabalhar em equipe

O profissional de saúde precisa se comunicar sem guardar conhecimento, sem reter informação, sem trabalhar isolado. “Comunicação é a chave do negócio. Hoje temos mais de 4 mil procedimentos cadastrados. Que profissional sabe a técnica correta de 4 mil procedimentos? Que médico sabe o nome de 6 mil medicamentos, as interações medicamentosas e as indicações? Não existe isso. Passou do nosso limite”, afirmou a Dra. Aline Yuri Chibana. Segundo ela, o resultado de termos ultrapassado esse limite e tentarmos processar tudo sozinhos é, por exemplo, que 60% dos pacientes com asma e 40% com doença arterial coronária que dão entrada nos nossos hospitais recebem tratamento incompleto ou inadequado. Além disso, 40% dos pacientes internados em nossos hospitais não irão receber profilaxia de TEV, porque a informação irá se perder em algum lugar, e esses pacientes irão morrer. Cada passagem de caso entre anestesistas aumenta a mortalidade do paciente em 8%, porque informações importantes se perdem.

Por isso, lembrou a Dra. Aline Chibana, de certa forma a saúde importou da aviação o uso do checklist, falado pelo Dr. Omar Mejia na palestra “Segurança do Paciente Cirúrgico”. “E checklist é de fato baseado em pausas, porque você só passa para a próxima etapa quando a atual está completa. É planejamento. Tem a parte do anestesista, do cirurgião, da enfermagem”, disse a Dra. Aline Chibana. Para ela, o uso do checklist melhorou em 47% a taxa de mortalidade simplesmente porque melhorou a comunicação entre o médico anestesista, o cirurgião e enfermagem. “É função de todos garantir que o paciente saia bem.”

A Dra. Aline Chibana lembrou a máxima que diz: “A segurança não é medida pelo número de vezes que você escorrega no gelo, e sim pela espessura dele”.  Ou seja, achamos que o hospital é seguro porque parece seguro em condições ideais, assim como o gelo. Mas só saberemos se é de fato, quando as coisas saírem do lugar ideal.

 

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