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

Abstract

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.

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

“…Among the errors, we may cite inaccurate values, incorrect setting and forgetting to turn on the pump after interruption (15)(16) . Infusion pumps account for 30-60% of all errors with intravenous medication, some of them requiring intervention for life maintenance (17) .…”

“…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) .…”

Prevenção De Complicações Evitáveis Em Uma Unidade De Terapia Intensiva: Uma Revisão Integrativa

“…As estratégias de prevenção de complicações evitáveis adotadas pelos enfermeiros nas Unidades de Terapia Intensiva estão diretamente relacionadas às complicações de Lesão por Pressão e contam com seis (66,6%) estudos, dosagens de medicamentos, hiper e/ou hipocalemia e cuidado de vias aéreas contam com um (11,1%) estudo cada (Quadro 2). -Uso de Check list e/ou protocolos para evitar esquecimentos e falhas nas programações e acompanhamentos das infusões; 17 -Padronizar os procedimentos e direcionar o trabalho. 17 Prevenção hiper e/ ou hipocalemia -Protocolo de controle de potássio por meio de um programa computacional (diminui o risco de ajuste incorreto da bomba de potássio, troca acidental de amostras é minimizado).…”

Cost-effectiveness of infusion pumps to reduce errors in a Pediatric ICU

“…Errors in venous infusions administered by infusion pumps are reported by nursing professionals; so much so that, in a study about lapses, slips and mistakes in the use of equipment in Intensive Care Units, a set of situations occurred in which there were errors that compromised patient safety. Among these, those involving infusion pumps (IP) were highlighted in the statements, due to the frequency of occurrence (3) .…”