Improving patient safety: how and why incidences occur in nursing care

Revista da Escola de Enfermagem da USP

Maria Cecilia Toffoletto¹  Ximena Ramirez Ruiz¹ 

关键词: Critical care;    Intensive Critical Care;    Nursing care;    Patient safety;    Root cause analysis;    Cuidados criticos;    Unidades de Terapia Intensiva;    Cuidados de enfermagem;    Seguranca do paciente;    Analise de causa fundamental;    Cuidados criticos;    Unidades de Cuidados Intensivos;    Atencion de enfermeria;    Seguridad del paciente;    Analisis da causa raiz;   

DOI  :  10.1590/S0080-623420130000500013

来源: SciELO

【 摘 要 】

The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU) in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

【 授权许可】

CC BY   
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