Patient safety: understanding human error in intensive nursing care

Author:

Duarte Sabrina da Costa Machado1,Stipp Marluci Andrade Conceição1,Cardoso Maria Manuela Vila Nova1,Büscher Andreas2

Affiliation:

1. Universidade Federal do Rio de Janeiro, Brazil

2. Hochschule Osnabrück, Germany

Abstract

ABSTRACT Objective: To analyze the active failures and the latent conditions related to errors in intensive nursing care and to discuss the reactive and proactive measures mentioned by the nursing team. Method: Qualitative, descriptive, exploratory study conducted at the Intensive Care Unit of a general hospital. Data were collected through interviews, participant observation and submitted to lexical analysis in the ALCESTE® software and to ethnographic analysis. Results: 36 professionals of the nursing team participated in the study. The analysis originated three lexical classes: Error in intensive care nursing; Active failures and latent conditions related to errors in the intensive care nursing team; Reactive and proactive measures adopted by the nursing team regarding errors in intensive care. Conclusion: Reactive and proactive measures influenced the safety culture, in particular, the recognition of errors by professionals, contributing to their prevention, safety and quality care.

Publisher

FapUNIFESP (SciELO)

Subject

General Nursing

Reference23 articles.

1. Patient safety: making health care safer,2017

2. To err is human: building a safer health system;Kohn LT,2000

3. Achieving a safe culture theory and practice;Reason J;Work Stress,1998

4. Human error;Reason J,2009

5. Documento de referência para o Programa Nacional de Segurança do Paciente,2014

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