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

Detalhes bibliográficos
Autor(a) principal: Toffoletto,Maria Cecilia
Data de Publicação: 2013
Outros Autores: Ruiz,Ximena Ramirez
Tipo de documento: Artigo
Idioma: eng
Título da fonte: Revista da Escola de Enfermagem da USP (Online)
Texto Completo: http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342013000501098
Resumo: 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.
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spelling Improving patient safety: how and why incidences occur in nursing careCritical careIntensive Critical CareNursing carePatient safetyRoot cause analysisThe 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.Universidade de São Paulo, Escola de Enfermagem2013-10-01info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersiontext/htmlhttp://old.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342013000501098Revista da Escola de Enfermagem da USP v.47 n.5 2013reponame:Revista da Escola de Enfermagem da USP (Online)instname:Universidade de São Paulo (USP)instacron:USP10.1590/S0080-623420130000500013info:eu-repo/semantics/openAccessToffoletto,Maria CeciliaRuiz,Ximena Ramirezeng2013-12-09T00:00:00Zoai:scielo:S0080-62342013000501098Revistahttp://www.scielo.br/reeuspPUBhttps://old.scielo.br/oai/scielo-oai.php||nursingscholar@usp.br1980-220X0080-6234opendoar:2013-12-09T00:00Revista da Escola de Enfermagem da USP (Online) - Universidade de São Paulo (USP)false
dc.title.none.fl_str_mv Improving patient safety: how and why incidences occur in nursing care
title Improving patient safety: how and why incidences occur in nursing care
spellingShingle Improving patient safety: how and why incidences occur in nursing care
Toffoletto,Maria Cecilia
Critical care
Intensive Critical Care
Nursing care
Patient safety
Root cause analysis
title_short Improving patient safety: how and why incidences occur in nursing care
title_full Improving patient safety: how and why incidences occur in nursing care
title_fullStr Improving patient safety: how and why incidences occur in nursing care
title_full_unstemmed Improving patient safety: how and why incidences occur in nursing care
title_sort Improving patient safety: how and why incidences occur in nursing care
author Toffoletto,Maria Cecilia
author_facet Toffoletto,Maria Cecilia
Ruiz,Ximena Ramirez
author_role author
author2 Ruiz,Ximena Ramirez
author2_role author
dc.contributor.author.fl_str_mv Toffoletto,Maria Cecilia
Ruiz,Ximena Ramirez
dc.subject.por.fl_str_mv Critical care
Intensive Critical Care
Nursing care
Patient safety
Root cause analysis
topic Critical care
Intensive Critical Care
Nursing care
Patient safety
Root cause analysis
description 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.
publishDate 2013
dc.date.none.fl_str_mv 2013-10-01
dc.type.driver.fl_str_mv info:eu-repo/semantics/article
dc.type.status.fl_str_mv info:eu-repo/semantics/publishedVersion
format article
status_str publishedVersion
dc.identifier.uri.fl_str_mv http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342013000501098
url http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342013000501098
dc.language.iso.fl_str_mv eng
language eng
dc.relation.none.fl_str_mv 10.1590/S0080-623420130000500013
dc.rights.driver.fl_str_mv info:eu-repo/semantics/openAccess
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv text/html
dc.publisher.none.fl_str_mv Universidade de São Paulo, Escola de Enfermagem
publisher.none.fl_str_mv Universidade de São Paulo, Escola de Enfermagem
dc.source.none.fl_str_mv Revista da Escola de Enfermagem da USP v.47 n.5 2013
reponame:Revista da Escola de Enfermagem da USP (Online)
instname:Universidade de São Paulo (USP)
instacron:USP
instname_str Universidade de São Paulo (USP)
instacron_str USP
institution USP
reponame_str Revista da Escola de Enfermagem da USP (Online)
collection Revista da Escola de Enfermagem da USP (Online)
repository.name.fl_str_mv Revista da Escola de Enfermagem da USP (Online) - Universidade de São Paulo (USP)
repository.mail.fl_str_mv ||nursingscholar@usp.br
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