Patient safety: understanding human error in intensive nursing care

Rev Esc Enferm USP. 2018 Dec 20:52:e03406. doi: 10.1590/S1980-220X2017042203406.
[Article in English, Portuguese]

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.

MeSH terms

  • Adult
  • Critical Care Nursing / standards*
  • Female
  • Hospitals, General / standards
  • Humans
  • Intensive Care Units / standards
  • Male
  • Medical Errors / prevention & control
  • Medical Errors / statistics & numerical data*
  • Middle Aged
  • Nursing, Team / standards*
  • Patient Safety*
  • Safety Management / methods