Objective: This study aims to analyze a non-conformity in the organ donation process, using a case from South Brazil, and develop a quality improvement tool to control the steps of organ donation, preventing future errors in donor management.
Methods: An exploratory descriptive study of the experience report type was conducted, employing the instrumental case study approach proposed by Robert Yin. Additionally, the Ishikawa diagram and brainstorming technique were utilized to analyze non-compliance in organ donation and propose a quality tool for process improvement.
Results: In a deceased organ donation case, the surgery to extract multiple organs proceeded smoothly. However, communication breakdowns led to inadequate family notification and body preparation, resulting in post-burial complaints. The analysis revealed discrepancies between documented and executed processes, prompting the development of a checklist for organ donation process verification. This checklist, tested in a pilot study and implemented in all donation processes, addresses notification, family communication, clinical assessments, documentation, and body preparation. Despite the irreversibility of the initial error, the study emphasizes the constructive use of quality tools for healthcare process analysis. The checklist addresses critical aspects, including notification protocols, family communication, clinical assessments, accurate documentation, and proper body preparation. The emphasis on communication, responsibility awareness, and effective procedural steps aligns with best practices in healthcare quality management.
Conclusions: The study's outcome, a publicly available quality tool, allows for future implementation studies, assessing the checklist's effectiveness in preventing organ donation process failures in Brazil. Furthermore, the study advocates for a constructive approach to errors in healthcare, steering away from punitive actions that might negatively impact involved parties. The resulting checklist, made publicly available, holds the potential for further implementation studies. This allows for an evaluation of its effectiveness in preventing organ donation process failures, contributing to the enhancement of organ donation practices in Brazil and potentially serving as a valuable model for healthcare improvement worldwide.