Analysis of risk classification activity in a high complexity school maternity: a contribution of ergonomics to patient safety.

 Risk rating. Screening. Patient safety. Adverse events. Maternity. Ergonomics.

   Ergonomics and Resilience Engineering have made an important contribution - with their systemic, situated and dynamic approaches - in the study of patient safety and the causality of the occurrence of adverse events with patients. This work is part of the patient safety domain, more specifically, in relation to the risk classification (CR) activity of patients in a high complexity obstetric care maternity school. Risk classification is a complex activity, as it is centered on the nurse's accumulated knowledge and experience (“risk classifier”), but it is also conditioned to the variability (technical, organizational and individual), the availability and reliability of information necessary for decision making, the density of work, the prescriptions, the network of workers involved, direct communications (worker-worker, worker-patient, worker-companion) and intermediated by technologies, the real context of work (variability, contracts, workload), the complexity of the patient's clinical condition, the number of demands per employee, the time available, etc. The risk classification process is characterized by the assessment of the patients' health status, by the risk classification itself, by the decision of the hierarchy of prioritization of care and by the initial referral of the patient for examination, clinical or surgical care in a hospital or maternity. As it is dynamic and complex, the risk classification process becomes crucial when the demand for service exceeds the organization's installed capacity for this purpose. One of the undesirable and avoidable occurrences, which can happen to patients, as a result of the risk classification process, are adverse events (AEs). AEs can occur due to clinical assessments, decision-making processes and inadequate referrals, resulting from the patient's risk classification process, which is one of the stages in the overall patient care process. The objective of this research is to analyze the determinants of risk classification activity that cause possible adverse events in patients. It is intended, with this, to propose improvements to the risk classification activity aiming at minimizing the occurrence of AEs and, consequently, improving the quality of care and patient safety. This research was carried out in the Risk Classification Sector of the Maternidade Escola Januário Cicco-MEJC of the Federal University of Rio Grande do Norte, in the city of Natal-RN, Brazil. Methodologically, field research and the ethnographic approach expressed by the Ergonomic Analysis of Work-AET was adopted, which is a situated research method. In this perspective, observational and interactional techniques were used to collect field data, considering the behaviors, cognitive processes and interactions mobilized by workers at the time of observations. Through these techniques and the Safety II approach advocated by Hollnagel, it was possible to understand how the risk classification process occurs, the distance between what was planned to carry out the risk classification (prescribed or imagined work) and what is actually does (real work or how it is carried out), the contrants, the variability, the adaptations adopted in this process, the relationship of these with the occurrence of possible adverse events and the strategies used by the workers to prevent or mitigate them. This made it possible to identify the direct relationship between the demand in the risk classification sector and the quantity of the team dimensioned for carrying out the activity. It was observed that, in order to meet the demand, nurses, in some cases, are pressured by patients and those responsible for carrying out the activity more quickly, causing an increased risk of process failures that can affect the reliability of the final classification result , making possible the occurrence of adverse events and compromising patient safety. On days when there is an increase in the demand for medical care and, consequently, in the risk classification, the nurses, in addition to carrying out the risk classification activity, need to deal with disagreements, which come, even aggressively, from the companions of the patients. patients, who charge quickly to perform the service. This fact could be seen in the most common peak service times, between 10 am and 12 pm and between 2 pm and 4 pm, and can be considered, according to nurses, one of the points that hinder the performance of the service. Another critical factor, which may be a cause of adverse events, reported by the team, and related to demand, is the fact that the risk classification process is marked by its instability. The health status of a patient may be aggravated during the wait, or, on the other hand, there may be an improvement while she waits for care. All teams involved in the risk classification work with the support of exchanging information through technical systems and with each other, providing a favorable cognitive environment for reducing contracts, managing variability and, therefore, reducing possible adverse events. In view of the complexity of the work (clinical conditions different from patients, with greater or lesser severity; greater or lesser urgency of care; difficult diagnosis, etc.) and the risks of the occurrence of adverse events, it is recommended that Maternity Hospital promotes the continuous training of nurses who perform the risk classification, both by improving the understanding and application of the Reception and Risk Classification Guide in Obstetrics and by discussing and simulating, collectively, the experienced and hypothetical cases and the possible strategies and approach procedures, aiming at continuous improvement the quality of the midwifery assistance service.