Patient safety: understanding human error in intensive nursing care

Duarte, Sabrina da Costa Machado; Stipp, Marluci Andrade Conceição; Cardoso, Maria Manuela Vila Nova; Büscher, Andreas

doi:10.1590/s1980-220x2017042203406

Cited by 27 publications

(32 citation statements)

References 10 publications

(33 reference statements)

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“…Medicament therapy chain is extensive, involves logistics focused on supply, prescription, dispensing, preparation and administration, which makes the identification of errors even more complex. It is possible that errors in this chain are related to systemic latent conditions (35) .…”

Section: Discussionmentioning

confidence: 99%

Indicators of effectiveness of nursing care in the dimension of patient safety

et al. 2020

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Objectives: to validate nursing care effectiveness indicators of patient safety dimension. Methods: quantitative survey, using the electronic Delphi sampli, with 52 participants selected by the Snowball sampling. Eight indicators were evaluated regarding the attributes: availability, reliability, simplicity, representativeness, sensitivity, comprehensiveness, objectivity, cost, utility, stability and timeliness. For validation, the minimum agreement criterion was 70%. Results: Cronbach’s alpha (0.942) evidenced the high internal consistency among the attributes. The indicators fall with damage, hip fracture, and postoperative hip fracture, incidents related to equipment, incidents due to failures in patient identification, and pressure injury were validated in all attributes, and those of medication error and hand Hygiene were not validated. Conclusions: the validated indicators allow assessment of the effectiveness of hospital nursing care. Unavailability of data is an obstacle to monitoring patient safety.

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Section: Discussionmentioning

confidence: 99%

Indicators of effectiveness of nursing care in the dimension of patient safety

et al. 2020

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“…patient safety and quality of care, hospital's social image) and quantitatively (e.g. medical dispute costs, patient compensation costs, number of patients, and medical income) [4]. Many medical errors occur infrequently, but they can shorten life or accelerate impending death.…”

Section: Why Is Patient Safety Important?mentioning

confidence: 99%

Can patient and family education prevent medical errors? A descriptive study

Kim

et al. 2020

BMC Health Serv Res

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Background: This study aims to increase understanding of how patient and family education affects the prevention of medical errors, thereby providing basic data for developing educational contents. Methods: This descriptive study surveyed patients, families, and Patient Safety Officers to investigate the relationship between educational contents and medical error prevention. The Chi-square test and ANOVA were used to derive the results of this study. The educational contents used in this study consisted of health information (1. current medicines, 2. allergies, 3. health history, 4. previous treatments/tests and complications associated with them) and Speak Up (1. handwashing, 2. patient identification, 3. asking about medical conditions, 4. asking about test results, 5. asking about behaviour and changes in lifestyle, 6. asking about the care plan, 7. asking about medicines, and 8. asking about medicine interactions). Results: In this study, the first criterion for choosing a hospital for treatment in Korea was 'Hospital with a famous doctor' (58.6% patient; 57.7% families). Of the patients and their families surveyed, 82.2% responded that hospitals in Korea were safe. The most common education in hospitals is 'Describe your medical condition', given to 69.0% of patients, and 'Hospitalisation orientation', given to 63.4% of families. The most important factors in preventing patient safety events were statistically significant differences among patients, family members, and Patient Safety Officers (p = 0.001). Patients and families had the highest 'Patient and family participation' (31.0% of patients; 39.4% of families) and Patient Safety Officers had the highest 'Patient safety culture' (47.8%). Conclusions: Participants thought that educational contents developed through this study could prevent medical errors. The results of this study are expected to provide basic data for national patient safety campaigns and standardised educational content development to prevent medical errors.

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“…É preciso que as pessoas que compõem as instituições de saúde saibam reagir e gerir as consequências da pergunta: quem foi? (Correia, Martins, & Forte, 2017;Duarte et al, 2018). O erro, quando revelado numa abordagem sistémica, que entende o processo de medicação como um sistema composto por etapas, deixa de ter carácter punitivo por parte dos gestores e passa a ter carácter educativo, propiciando um ambiente de crescimento intelectual (Ministério da Saúde, 2014).…”

Section: Enquadramentounclassified

“…A administração de um medicamento de forma correta pode configurar-se como uma atividade simples, no entanto, um enfermeiro pode administrar mais de 100 mil fármacos durante toda a sua carreira. Assim, é difícil imaginar que não ocorrerão erros, sobretudo quando não há barreiras ou sistemas de prevenção (Duarte, Stipp, Cardoso, & Büscher, 2018). Vale ressaltar que, no Brasil, a equipa de enfermagem é composta por profissionais de nível superior e médio: enfermeiro e técnico de enfermagem, respetivamente.…”

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