Revista da Escola de Enfermagem da USP (Dec 2018)

Patient safety: understanding human error in intensive nursing care

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

DOI
https://doi.org/10.1590/s1980-220x2017042203406
Journal volume & issue
Vol. 52, no. 0

Abstract

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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.

Keywords