Objective:To identify the occurrence of errors in the use of equipment by nurses working in intensive care and analyzing them in the framework of James Reason's theory of human error. Method: Qualitative field study in the intensive care unit of a federal hospital in the city of Rio de Janeiro. Observation and interviews were conducted with eight nurses, from March to December 2014. Content analysis was used for the interviews, as well as the description of the scenes observed. Results: Lapses of memory and attention were identified in the handling of infusion pumps, as well as planning failures during the programming of monitors. Conclusion: Errors cause adverse events that compromise patient safety. The authors propose creation of an instrument for daily checking of equipment, with checks throughout the work process in the programming of infusion pumps and monitors, in order to reduce failures and memory lapses.

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Objective: to identify situations of violation in the use of equipment by nurses in the intensive care unit and analyze their implications on patient safety. Method: a descriptive field study with qualitative approach was carried out from March to December 2014, with the use of James Reason's violation concept. The participants were nurses from the day shift, working in direct care at an intensive care unit of a federal hospital. Data production was carried out through systematic observation and interviews, and were analyzed based on thick description of scenes and content of responses. Results: violations in planning care regarding the checking of the equipment functioning before its use and alarms were found, when nurses disconnect them to reduce the effects caused by the overload of noise on the team. Conclusion: the situations reported compromise safety and cause serious risks to patients. Therefore, implementation of strategies to promote a safety culture is required.

915Rev Bras Enferm [Internet]. 2016 set-out;69 (5) ABSTRACT Objective: to identify the causes of adverse events affecting clients resulting from the use of equipment in intensive care services; to point out the main recommendations for clinical practice to minimize these events and, then, discuss the implications to nursing care. Method: integrative and descriptive review on the SciELO, Medline, LILACS, and PubMed databases. Articles were selected based on the inclusion criteria and the structured instrument was applied. Results: altogether, 11 articles were selected where three evidence units were outstanding: Equipment failure; inadequate use of equipment; and team failure. Permanent education of professionals; evaluation of production and availability of equipment; and use of checklists are recommended. Conclusion: preventing adverse events related to equipment is one of the nursing responsibilities and requires the establishment of defensive barriers to prevent these. Descriptors: Biomedical Technology; Intensive Care Units; Nursing; Patient Safety; Nursing Care. RESUMO Objetivo: identifi car as causas de eventos adversos no cliente relacionados aos equipamentos presentes no cenário de terapia intensiva; indicar as principais recomendações à prática clínica para minimizar tais eventos e, então, discutir as implicações na assistência de enfermagem. Método: revisão integrativa, descritiva, realizada nas bases SciELO, Medline, Lilacs e Pubmed. Para seleção dos artigos, foram adotados critérios de inclusão e aplicado instrumento estruturado. Resultados: captou-se um total de 11 artigos, nos quais sobressaem três unidades de evidência: falha do equipamento, uso inapropriado do equipamento e falha da equipe. Recomendam-se: educação permanente dos profi ssionais; avaliação da produção e disponibilidade dos equipamentos; e uso de checklists. Conclusão: a prevenção de eventos adversos com equipamentos é uma das responsabilidades da enfermagem e, nesse sentido, é relevante a criação de barreiras defensivas para evitá-los. Descritores: Tecnologia Biomédica; Unidades de Terapia Intensiva; Enfermagem; Segurança do Paciente; Cuidados de Enfermagem. RESUMENObjetivo: identifi car las causas de eventos adversos del usuario, relacionados con los equipamientos presentes en el ámbito de terapia intensiva; indicar las principales recomendaciones a la práctica clínica para minimizarlos; y discutir consecuentemente las implicaciones en la atención de enfermería. Método: revisión integrativa, descriptiva, realizada en bases de datos SciELO, Medline, Lilacs y Pubmed. Artículos seleccionados por criterios de inclusión adoptados, aplicándose instrumento estructurado. Resultados: Se obtuvieron en total 11 artículos, sobresaliendo tres unidades de evidencia: falla de equipamientos, uso inapropiado del equipamiento y falla del grupo. Se recomendó: educación permanente de profesionales; evaluación de producción y disponibilidad de equipamientos; y uso de check-list. Conclusión: la prevención de eventos adversos por equipamientos es respon...

It is necessary to strengthen the monitoring systems of safety conditions of equipment in intensive nursing care to prevent incidents.