A dupla conferência na síntese de radiofármacos : uma barreira para mitigação de erros?

Abstract

This Ergonomic Work Analysis was carried out in a Radiopharmaceutical Research and Production Unit, whose demand, after its proper instruction and reformulation, related to a non-conformity identified in a self-inspection carried out by the unit's workers: the absence of double verification in the cassette assembly. This checking process is determined in an internal procedure, in order to prevent or minimize possible errors in the assembly of the cassette components that could culminate in the production of a radiopharmaceutical outside the quality parameters, or even with the cancellation of production, by process failure. The objectives of this study were: to know the activities of workers, especially the stage of radiopharmaceutical synthesis, to identify what the double conference consists of (self-conference), and to explore the strategies that operators use, which aim to mitigate the possibilities of errors in the production process. Through the analysis of the activity with the workers in the production room, it was identified that, although the double check was not carried out, that is, the checking of the cassette assembly by a second person, there were a series of operating modes developed by the official operator of the synthesis that, during and after the assembly, were contributing to the mitigation of complications. Such strategies were called “self-conference”. Through discussion with the collective of workers, it was concluded that the existing conferences (double conference, self conference and system conference) were complementary. Thus, recommendations were suggested that would allow a learning space, close without communication between operators and that conferences were prescribed, based on the actual work activity, in order to meet the production needs and to adapt to the opportune moments defined by the operators.