Human error in daily intensive nursing care

Abstract

Objectives: to identify the errors in daily intensive nursing care and analyze them according to the theory of human error. Method: quantitative, descriptive and exploratory study, undertaken at the Intensive Care Center of a hospital in the Brazilian Sentinel Hospital Network. The participants were 36 professionals from the nursing team. The data were collected through semistructured interviews, observation and lexical analysis in the software ALCESTE(r). Results: human error in nursing care can be related to the approach of the system, through active faults and latent conditions. The active faults are represented by the errors in medication administration and not raising the bedside rails. The latent conditions can be related to the communication difficulties in the multiprofessional team, lack of standards and institutional routines and absence of material resources. Conclusion: the errors identified interfere in nursing care and the clients' recovery and can cause damage. Nevertheless, they are treated as common events inherent in daily practice. The need to acknowledge these events is emphasized, stimulating the safety culture at the institution.

Slips, lapses and mistakes inthe use of equipment by nurses in an intensive care unit

“…Most studies dealing with adverse events in the context of nursing care (10)(11) identify faulty use of equipment as one of its causes; however, they do not delve into the characteristics of these incidents in a manner that contributes to the understanding of how and why they occur, so that effective interventions can be adopted. To improve the quality of care, the NPSP foresees the creation of a protocol on the application of technologies.…”

Validation of an instrument regarding nursing intervention in patients in vasoactive therapy

“…Transforming the practice of medication administration is one of the strategies to involve the professionals in the topic of safety in drug therapy, always with the intention of minimizing factors that could cause error. In addition, as part of the nurses' role, nurses should develop research and frequent consults to other health professionals and to literature (15,(22)(23) .…”

Patient safety: understanding human error in intensive nursing care

“…scenario "The study setting was the Intensive Care Unit (ICU) of a general federal public hospital member of the Brazilian Network of Sentinel Hospitals of the Brazilian Health Surveillance Agency (ANVISA -Agência Nacional de Vigilância Sanitária)" (9) . The ICU has 22 beds, divided into three sectors: ICU 1 (10 beds), ICU 2 (9 beds), and Annex (4 beds).…”

“…The inclusion criteria were: being a permanent employee/public servant, "being allocated at the ICU, and working in the sector for more than 6 months. The exclusion criteria were: being on leave from the ICC during the data collection period due to holidays and other leaves" (9) . daTa collecTion After applying the described criteria, 63 professionals (22 nurses and 41 nursing assistants were selected).…”