Improving patient safety

How and whyincidences occur in nursing care

María Cecilia Toffoletto, Ximena Ramirez Ruiz

Resultado de la investigación: Article

Resumen

The present investigation was a crosssectional, 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.

Idioma originalEnglish
Páginas (desde-hasta)1098-1105
Número de páginas8
PublicaciónRevista da Escola de Enfermagem
Volumen47
N.º5
DOI
EstadoPublished - oct 2013

Huella dactilar

Root Cause Analysis
Patient Safety
Nursing Care
Device Removal
Chile
Public Hospitals
Intensive Care Units
Technology
Incidence
Research
Therapeutics

ASJC Scopus subject areas

  • Nursing(all)

Citar esto

Toffoletto, María Cecilia ; Ruiz, Ximena Ramirez. / Improving patient safety : How and whyincidences occur in nursing care. En: Revista da Escola de Enfermagem. 2013 ; Vol. 47, N.º 5. pp. 1098-1105.
@article{3023d800526847cf88cf18b17719df3c,
title = "Improving patient safety: How and whyincidences occur in nursing care",
abstract = "The present investigation was a crosssectional, 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.",
keywords = "Critical care, Intensive Critical Care, Nursing care, Patient safety, Root cause analysis",
author = "Toffoletto, {Mar{\'i}a Cecilia} and Ruiz, {Ximena Ramirez}",
year = "2013",
month = "10",
doi = "10.1590/S0080-623420130000500013",
language = "English",
volume = "47",
pages = "1098--1105",
journal = "Revista da Escola de Enfermagem da U S P.",
issn = "0080-6234",
publisher = "University of Sao Paolo",
number = "5",

}

Improving patient safety : How and whyincidences occur in nursing care. / Toffoletto, María Cecilia; Ruiz, Ximena Ramirez.

En: Revista da Escola de Enfermagem, Vol. 47, N.º 5, 10.2013, p. 1098-1105.

Resultado de la investigación: Article

TY - JOUR

T1 - Improving patient safety

T2 - How and whyincidences occur in nursing care

AU - Toffoletto, María Cecilia

AU - Ruiz, Ximena Ramirez

PY - 2013/10

Y1 - 2013/10

N2 - The present investigation was a crosssectional, 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.

AB - The present investigation was a crosssectional, 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.

KW - Critical care

KW - Intensive Critical Care

KW - Nursing care

KW - Patient safety

KW - Root cause analysis

UR - http://www.scopus.com/inward/record.url?scp=84890863861&partnerID=8YFLogxK

U2 - 10.1590/S0080-623420130000500013

DO - 10.1590/S0080-623420130000500013

M3 - Article

VL - 47

SP - 1098

EP - 1105

JO - Revista da Escola de Enfermagem da U S P.

JF - Revista da Escola de Enfermagem da U S P.

SN - 0080-6234

IS - 5

ER -