5.

RISK IDENTIFICATION

Delegation: Sinaloa

Medical services unit: General Regional Hospital # 1 Date: June 20, 2018

RISK IDENTIFICATION

No. Risks Weighting

Impacto Probabilidad
of occurrence
1 Non-compliance with the registration regulations of 4 4
nursing staff in relation to filling
deficient clinical records sheet and
therapeutic and nursing interventions
2 Failure in the management of nursing staff in 4 4
the prevention of pressure ulcers
hospitalized patient associated with:
• Deficiency in the revaluation and of
according to patient's condition the
interventions of nursing
established in the care plan.
• Lack of implementation of mobilization
of the patient by nursing
3 Inadequate working environment for staff of 3 3
Surgery department nursing that
it can affect the attention given to the patient referred
de:
• The workload per template of
insufficient or uncovered personnel in
relationship between nurse-patient index.
 RISK IDENTIFICATION

No. Risks Weighting

Impact Probability of
occurrence
4 Cross-transmission risk of 3 3
microorganisms in hospitalized patients
from the department of surgery associated with the
lack of the implementation of measures of
caution from the health personnel of the
service, due to: lack of rooms
sufficient isolation, ignorance by
part of the health personnel and lack of cards
isolation at the patient's head,
as well as lack of supervision of attachment
to this procedure.
5 Risk of adverse event due to falls of 3 3
hospitalized patient from the department of
surgery due to improper handling by
part of the health personnel in prevention of
falls related to:
• Little user orientation and
familiar with the use and management of
team and the elements for the
patient safety.
• No record in presence or absence
of incident or accident that is
present.

6 Lack of adherence to the guidelines that guide the use 3 3

of resuscitation services including
reception, delivery, and content of the CARE,
considerably affecting in case of a
incident with repercussions on the patient.
7 Risk of infection associated with care 2 3
health related to the lack of attachment to
the requisition of solution letterheads and
venous infusion equipment, which causes not
llevar un control adecuado de días de
catheter installation.
 RISK IDENTIFICATION

No. Risks Weighting

Impact Probability of
occurrence
8 Failure in the proper management of personnel 3 2
nursing in infection prevention
urinary tract in patient with catheter
Foley with risk of causing an event
adverse or harm to the health of the hospitalized
in eastern surgery,

Nombre de quien elabora:LEO. Eloy Baeza García

Nombre de quien autoriza:Lic. Josefina flores Carrasco

5. RISK IDENTIFICATION

PUNCTUATION
 6. RISK MAP

Delegation: ________________________

Medical services unit: _______________________ Date: _______________

0 Attention risks Attention risks 0

periodic immediate

5
5
Controlled risks Risks of
follow-up

0 0

IMPACT

Nombre de quien elabora:_________________________

Name of the authorizer: _________________________

7. CLASSIFICATION OF RISKS
Delegation: ______________________

Medical services unit: _______________________ Date: _______________

RISK CLASSIFICATION

RISK OF RISK OF
TYPES OF RISK OF RISKS
ATTENTION ATTENTION
RISK MONITORED TRACKING
IMMEDIATE PERIODIC

RISKS
CLINICALS

RISKS OF
MANAGEMENT

Name of the person who prepares: _________________________

Name of the person authorizing: _________________________

8. INTERVENTION MATRIX
Delegation: ________________________

Medical services unit: _______________________ Date: _______________

INTERVENTION

No. Risk Actions for Goal to achieve Date of Report of

risk decrease the compliance advances
risk

Name of the person who prepares: _________________________

Name of the authorizer: _________________________

9. STRATEGIC DIAGNOSIS

9.1 SWOT Analysis.

Delegación: ________________________
Medical services unit: _______________________ Date:_______________
Generic Function: ____________________________

Fortresses Weaknesses

Opportunities Threats

9.2 Deployment of strategies

1.- FO strategies 2.- FA Strategies

3.- DA Strategies 4.- DO Strategies

Nombre de quien elabora: _________________________

Name of the authorizer: _________________________

9. STRATEGIC DIAGNOSIS
9.1.1 MANAGEMENT PROCESS
 9.1.S.W.O.T. Analysis.
Fortresses Weaknesses

F1. Strategic planning approach based on the Model for D1. Insufficient knowledge and training on the guidelines.
the executive management of nursing 2660-003-053 in the management of nursing executive staff.
F2. Manual of procedures for medical care in the D2. Lack of adherence to the regulation supervision of the processes.
hospitalization process 2660-003-056 nursing and medical care
F3. Disponibilidad de tecnologías de la información y la D3. Falta de apego coordinación en la programación de periodos
communication. vacations, breaks and covers for vacations
F4. Assertive communication between the floor manager and the deputy manager of D4. Deficit in the continuity of managerial services.
service related to the lack of compliance with the linkage regulations of
F5. Collective labor agreement shift (operating instructions for nursing services in
F6. Have a strategic program of hospitalization action lines 2660-005-004
MIPRIN D5. Absence of the welcome manual in the service that provides guidance
F7. Stimuli and recognition for administrative staff regarding the organization and functionality of the service.
quality of the services D6. Lack of adherence to the strategic plan regarding its development
F8 Bed Management Program of exclusive managerial folder for service 2660-003-053
D7. Decrease in adherence and attachment to the institutional vision
D8. Ignorance of the different manuals of
procedures performed in the service.
D9. Lack of event logging for quasi-failure events, adverse events,
sentinels (VENCER II system)
Opportunities Threats
A1. Low budget allocated to the healthcare area at the federal level
Legal framework governing the rights and obligations of A2. Universalization of health services
healthcare professionals A3. Various approaches to health management taught
O2 Official Mexican Standards that govern the processes of for educational institutions that do not align with the needs
healthcare. management in IMSS
O3 external organisms that recognize the competitiveness of the A4. Fluctuating population with entitlement by season
medical care facilities through the process of agricultural
hospital certification A5 heterogeneity in health service programs
O4 Management and patient-centered standards that regulate A6. Insufficient knowledge of the managerial staff of the
health care with a quality focus strategic planning processes
O5 Technology adopted for the recording of activities in health service programs
nursing
O5 Hospital Certification
9.1.2 Deployment of strategies
1.- FO strategies 2.- FA Strategies

F1-O2, O4.- Optimize the service processes according to F1, F2, F4/A3.- Unify the management approach, adhering to
manuals of procedures in accordance with existing regulations model of nursing management 2660-003-053
y a the international criteria established for making known the institutional regulations that govern the
patient quality/safety. health care.

3.- DA Strategies 4.- DO Strategies

D1/A5, A6.- Coordinate the administrative training of the D2-O1, O2.- Implement training on the framework
managerial guidelines in accordance with the homogenization of the regulatory and legislative scope for the personnel that facilitates the
processes to management approaches healthcare assistance processes, through the knowledge of the
D6/A3,A5.- Standardize administrative tools, diagnose official standards governing the service
situational, work program and supervision program with D9/O1.O4 - Disseminate the Vencer II System and its methodology
attachment to the management model report, through the correct filling of the form.

9.2. HUMAN TALENT MANAGEMENT PROCESS

9.2.1 SWOT Analysis.

 Fortresses Weaknesses
F1. Newly hired qualified staff with a bachelor's degree D1. Insufficient staff distribution in relation to the nurse ratio.
F2. Incidental education within services patient.
F3. Geriatric nurse in the service. (Continuous training on D2. Mobilization of human talent to other services as needed
healthcare procedures for the prevention of pressure ulcers hospital
Willingness to work in teams. D3. Disinterest in continuing education, research and
F5. Access to the Internet, to the use of technology. participation in clinical and interdepartmental sessions.
F6. Distance training with online diplomas-coordination of D4. Unsatisfactory work environment resulting from workload overload
health education D5. Incidence of scheduled and unscheduled absenteeism of personnel
F7. Institutional program for incentives and recognition of performance of nursing
quality of base nursing staff (PRACENF) 2900-003- D6. Low work performance of nursing staff due to burnout
004 physical.
F8 Professionalization and leveling to bachelor's degree of UNAM staff D7. Lack of knowledge of quality indicators, manuals
ENJOYED (fortress) procedures and guidelines.
F9 Right to scholarship or leave for attendance at training for D8. Lack of empathy and depersonalization among operational staff
nursing burnout
F 10 Internships of the nursing degree. D9. Deficit in the induction process for new staff
F11 Being a teaching hospital income
F12 opportunity for institutional promotion in the hierarchy D10. Uncertainty about the future of social security and regimes of
F13. Standards, policies, and procedure manuals of the service. pensions
F14. Catalog of monographic courses and on-the-job training D11. Restlessness of the nursing staff caused by the
F15. Personnel coverage for overtime, for coverage of constant legal demands and assaults affecting the staff,
the demand for services derivatives of grievances in user health care.
F16. Worker substitution program. D12 Unawareness of the public servant's code of conduct and
nursing code of ethics
Opportunities Threats
O1. National and international congresses and conferences A1. Legal claims for failure of professional responsibility of
O2. Offer of nursing degree, diplomas, master's degrees and nursing.
doctoral degrees recognized by different educational institutions at the level A2. Increase in insecurity and violence in the area of influence of the
national and international unit in the last 6 months.
Use of ICT that promotes updating and professionalization A3. Nursing graduates who do not identify with the essence of the
of nursing. profession.
O4. Professional organizations that promote action A4. Negative advertising by the media.
professional and ethical nursing, (nursing college, etc) A5. Universalization of health services
O5 Post-technical courses taught and accredited by educational institutions A6. Nursing human resource with technical academic level
recognized at the national level predominant in the state
O6 Scientific nursing journals with updated information
O7. Code of professional ethics for nursing and deontological codes
international
Nursing certification in the different specialties.
9.2.2 Deployment of strategies
1.- FO Strategies 2.- FA Strategies
F7,F12/O2,O3,O4 Spread the advantages of the curricular increase F8/A6.- Promote the leveling of the bachelor's degree for personnel with the level
(conferences, courses either as a speaker or attendee) for the technical academic, that stimulates the professionalization of nursing.
recognition of nursing performance (PRACENF) F3/A1.- Coordinate health education activities regarding
F9,F14,F16/O1 Promote prevention of pressure ulcers, to nursing staff and users in
bedridden patients, who reduce prolonged stays and risks
for the patient's integrity

3.- DA Strategies 4.- DO Strategies

D11/O4.- Align the integration of health personnel into bodies
D4,D8/A1.-Disseminate information about emotional exhaustion collegiate bodies, which help to unify the nursing profession, and
(Burnout) and psychological support that encourages health professionals que permitan a sus integrantes obtener apoyo y beneficios jurídicos ante
to avoid depersonalization and negative iatrogenesis in daily life the demands or aggressions arising from attention.
act according to its function. D3/O1,O5,O6.- To inform the nursing staff about the existence of
D11, D12/A1, A2, A4.- disseminate among the staff the legislation that strengthens post-technical courses offered by external organizations that are
knowledge in their professional performance to reduce the risk of recognized by the institution to participate in the promotion
legal demands. promotions and ranks

9.3. MATERIAL RESOURCES MANAGEMENT PROCESS

 9.3.1 SWOT Analysis.
Fortresses Weaknesses
F1. Have qualified personnel for preventive maintenance and Insufficient amount of common use electromedical equipment
corrective maintenance of electromedical devices by institution personnel. infusion pumps, ventilators, monitors, electrocardiographs,
F2. Notebook for use and marking of the narcotics control notebook defibrillators, etc.)
psychotropics in the service D2. Inadequate physical space distribution according to NOM 016-
F3. Tecnología adaptada al servicio. (computadora e impresora) SSA3-2012
F4. Procedure for determining fixed allocation, request, D3. Oxygen tanks and insufficient air for service demand
supply, custody and control of medications in the units D4. Inadequate use of institute resources and deterioration of
second level hospital medical services 2660-003-023 service furniture
F5. Procedure for determining needs and control of D5. Deficiency in the supply of hand hygiene materials
reusable hospital clothing in hospital medical units of the (MISP No. 5)
Mexican Institute of Social Security. 2430-003-007 D6. Inadequate supply of hospital clothing for 24 hours according to
F6 Formats for the control and evaluation of the quality of the materialfixed provision
consumption (technical control unit RQME-1) D7. Replenishment of Poor Quality Materials and Supplies.
D8. Irregularity in the routine inspection for maintenance
preventive and corrective maintenance of electromedical equipment.
D9. Inadequate supply of medications in collective format in
based on the request.
D10.- insufficient fixed fund for consumables, medicines and
breakage.
D11.- Losses and extraordinary exits of high-cost medications
and psychotropic in the service.
Opportunities Threats
Coordination with other public health system organizations
and private ones, to provide the services. A1. Low budget allocated to the federal level healthcare area.
O2. Official standard 016-SSA3-2012 that establishes the minimum requirements A2. Suppliers that offer material resources at a low cost that do not
of hospital infrastructure and equipment and care clinics they meet the real needs demanded by users.
specialized doctor. A3. Epidemiological transition
O3. Agreements with other health institutions for provision of A4. Accelerated technological advance that surpasses the infrastructure and
material and equipment. unit equipment.
O4. Updated clinical practice guidelines for calculation of A5. Increase in demands for attention due to lack of supply in the
medication and material medicine.
O5 External providers. A6. Administrative and criminal penalties for non-compliance with your
professional responsibility.
9.3.2 Deployment of strategies
1.- FO Strategies 2.- Estrategias FA

F2, F4/O4.- Strengthen adherence to the clinical practice guideline for F6/A2. Incorporate report tracking into the consumable material
update and the calculation of medication in the institution for the of poor quality, for its replacement or substitution.
correct request and determination of fixed cash fund allocation to the service of
internal medicine.

3.- DA Strategies 4.- Estrategias DO

D1, D3/A3. Strengthen the process of compliance with the official standard D1, /O1, O3.- Communicate equipment needs in a timely manner,
Mexican 016-SSA3-2012, to meet the health demand of to provide appropriate medical care in coordination with the chief
beneficiary. of service
D10,D11/A5: Coordinate the request, supply, storage, safekeeping and
medication control to minimize the risk of lawsuits for
lack of resource

9.4. CARE MANAGEMENT PROCESS

 9.4.1 SWOT Analysis.
Fortresses Weaknesses
F2. Monographic courses on the implementation of NANDA NIC NOC in the D1 Resistance and Unknowns of the nursing processes based
nursing record in the NANDA-NIC-NOC taxonomy
F3. Scholarship System for IMSS and AUTE worker D2. Apathy on the part of nursing staff in the programs of
F4.- action lines of the institutional model for prevention and registration continuing education
of nosocomial infections (MIPRIN) D3. Insufficient knowledge of related regulations and guidelines
F5. Standardized model for managerial management 2660-003-053 with health care.
F6. Manual of procedures for medical care in the process of D4. Insufficient training of human talent on actions
hospitalization 2606-003-056 according to the procedure manuals.
F7. Current technical-administrative instruments and regulations. D5. Lack of knowledge and application by the staff of
F8. Manuals of organization and normative and operational procedures nursing on assessment scales and how to interpret them,
F9. To be a teaching hospital. EVA, BRADEN)
F10. Have a unit for teaching and research in health. D6. Desinterés en la aplicación adecuada del proceso enfermero y
F11. Application of quality indicators in nursing care. formulation of diagnoses.
F12. Quality indicators of nursing care as a standard D7 Insufficient correlation of medical indications with actions of
to monitor the quality of care. nursing.
F13. Follow-up of the VENCER II program D8 Deficiency in the correct filling out of the clinical records sheet
F14. Distance education and training by the benefits management therapeutic.
medic D9 Lack of adherence to the PUPPPH quality indicator.
F15.- Adoption of the nursing care methodology for record-keeping D10 shift link not in accordance with the current regulations of the instruction
correct the nursing interventions. operation for nursing services in hospitalization 2660-005-
F16.- institutional regulation as a legal-ethical framework that strengthens the 004
training and induction for new staff to the position
income
F17 assessment scales adopted by the institution that allow for the
comprehensive assessment of the patient
Opportunities Threats

O1. Methodology of the nursing care process, NANDA, NIC, NOC A1. Increase in the user population that interferes with the quality of the
to standardize care plans. nursing service attention
O2. Internet access and databases with virtual content about A2. Complexity of epidemiological behavior
health topics, epidemiological data, manuals, practice guidelines A3. Increase in insecurity and violence in the area of influence of the
clinic and assessment scales. unity in the last 6 months
O3 Distance study plan SUAyED ENEO-UNAM A4 Heterogeneity in patient care nursing care

9.4.2 Deployment of strategies

1.- FO Strategies 2.- FA Strategies
F2, F6, F15, F17 /O1.- Implement interdepartmental education that
strengthen the correct filling of the nursing sheet and the integration F3, F9/A1.- Take advantage of being a teaching hospital with available scholarships,
from the nursing diagnostic process to the clinical record sheet of to provide the appropriate training for nursing professionals
nursing according to Annex 5 of procedure manual 2660- according to the quality requirements promoted by the institution.
003-056 F4/A2: Supervise the activities in adherence to the line of action
F2, F9 F10, F14/O1,O2 Coordinate the update of the application MIPRIN to decrease or limit intra-hospital complications,
application of the nursing process, taking advantage of the facilities of applying checklists for each line of action.
teaching and technological resources of the teaching unit.

3.- DA Strategies 4.- DO Strategies

D1, D3/A3. Strengthen the process of compliance with the official standard D1/O1.-integrar la metodología del proceso cuidado enfermero
Mexican 016-SSA3-2012, to meet the health demand of (NANDA-NIC-NOC) taking advantage of technological resources (internet),
beneficiary. for its application in nursing care processes.
D10,D11/A5: Coordinate the request, supply, storage, custody and
D5,D9,D8/O2.- Promote and impart topics on clinical records, on
control of medications to minimize the risk of lawsuits due to
lack of resource valuation scales, and adherence to the quality indicator of PUPPPH,
through manuals, clinical practice guidelines, and assessment scales.
 10. PROCESS MAP

START

1 3

ACTIVITY
KEY
4 5
2 YES
NO
POINT
CRITIC

FIN