Nursing in critical care: the perception of errors and risk management Errors in critical care
Main Article Content
Abstract
Objectives: Safety culture refers to the summary of perceptions that employees share about the safety of their work environment. We sought to identify the most frequent errors occurring in critical care area and the related contributing factors perceived by critical care nurses.
Methods: A questionnaire was filled anonymously by a convenience sample of 220 critical care nurses. The first five questions aimed to explore the hospital’s risk management organizational structure. The following seven questions investigated the nurses’ perceived causes of adverse events/near misses
Results: The mean number of reported errors is 3.5±1.6. The most frequent reported categories of errors are: the drug related errors (n=269, 34%), errors in the management of medical equipment (n=190, 24%) and procedural errors (n=123, 16%). The most frequent perceived causes with a great” impact on adverse events/near misses were: 1) communication’s problems (n=62, 28.2%), 2) lack of structures (n=54, 24.5%) and 3) problems of “leadership” (n=49, 22.3%).
Conclusions: A planned strategy of improvement needs to be created to clarify problems, undertake improvement actions and strategies that will help the team to work safely.
Keywords:
patient safety, nursing, critical care, errors
Article Details
How to Cite
VIDA, Vladimiro L et al.
Nursing in critical care: the perception of errors and risk management.
Medical Research Archives, [S.l.], v. 6, n. 12, dec. 2018.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/1888>. Date accessed: 27 dec. 2024.
doi: https://doi.org/10.18103/mra.v6i12.1888.
Section
Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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30. Evans SM. Attitudes and barriers to incident reporting: a collaborative hospital study.Quality and Safety in Health Care 2006;15(1):39-43.
31. Benn J, Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care 2009;18(1):11-21.
32. McFadden KL, Stock GN, Gowen III CR. Leadership, safety climate, and continuous quality improvement: Impact on process quality and patient safety. Health care management review 2014.
33. Despins Laurel A. Patient safety and collaboration of the intensive care unit team. Critical care nurse 2009;29(2):85-91.
34. Papaspyros SC, Javangula KC, Adluri RKP, O'Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interactive cardiovascular and thoracic surgery 2010;10(1):43-47.
2. International Council of Nurses 2013. Position Statement. Patient Safety. www.icn.ch/images/stories/documents/publications/position_statement. Published 2013. Accessed on September 1,2014.
3. The future of Nursing, The future of Nursing: Leading Change, Advancing Health – Report Briefing, October 2010. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Release.aspx. Accessed on September 1, 2014.
4. Holmes A. Transforming education. Nursing management 2011; 42(4):34-38.
5. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P. Quality and safety education for nurses. Nursing outlook 2007;55(3):122-131.
6. The European Federation of Nursing Association (EFN) position paper on safety. http://www.icn.ch/pspatientsafe.htm - http://www.whpa.org/factptsafety.htm. Accessed on September 1, 2014.
7. Chang SY, Multz AS, Hall JB. Critical Care organization. Critical care clinics 2005;21 (1):43-45.
8. Flin, Rhona H., Paul O'Connor, and Margaret Crichton. Safety at the sharp end: a guide to non-technical skills. Ashgate Publishing, Ltd.2008. ISBN: 978-0-7546-4600-6
9. Ministero Della Salute. Risk Management in Sanità: il problema degli errori. Commissione Tecnica sul Rischio Clinico. http://www.salute.gov.it/imgs/c_17_pubblicazioni_583_allegato.pdf). Published in 2008. Accessed June 2, 2014.
10. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System (Vol. 627). National Academies Press 2000. Washington DC. ISBN: 978-0-309-26174-6
11. The HealthGrades Press Releases Pages. http://www.healthgrades.com/pressroom/tv. Accessed on August 2, 2014.
12. Lahue BJ, Pyenson B, Iwasaki K. National burden of preventable adverse drug events associated with inpatient injectable medications: healthcare and medical professional liability costs. Am Health Drug Benefits 2012;5:413-422.
13. Kiekkas P, Aretha D, Stefanopoulos N, Baltopoulos GI. Knowledge is power: studying critical incidents in intensive care. Crit Care 2012;16(1):102.
14. Bracco D, Favre JB, Bissonnette B, Wasserfallen JB, Revelly JP, Ravussin P, Chioléro R. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive care medicine 2011;27(1):137-145.
15. Welters Ingeborg D. Major sources of critical incidents in intensive care. Crit Care 2011; R232.
16. Carayon P. Human Factors of complex sociotechnical system. Application Ergonomics 2006;37:525-535.
17. Holden RJ, Scanlon MC, Patel NR, Kaushal R, Escoto KH, Brown RL, Karsh BT. A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ quality & safety 2001;20(1):15-24.
18. The Joint Commission. Accreditation Program: Hospital-National Patient Safety Goals. http://www.jointcommission.org/NR/rdonlyres.pdf. Accessed on August 2, 2014.
19. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug safety 2009;32(5):379-389
20. Benoit E, Eckert P, Beney J. Medication errors on intensive care units: don't underestimate the risks due to transcription. Journal de pharmacie de Belgique 2012;(1):28-35.
21. Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Patient safety leadership walkrounds. Joint Commission Journal on Quality and Patient Safety 2003;29(1):16-26.
22. Poletti P. Safety Walkaround. Care 2009;2:27-33.
23. Verran JA. Quality of care, organizational variables and nursing staffing. Nursing Reserch 1999;47:43-50.
24. Van Rosse F, Maat B, Rademaker CM, van Vught AJ, Egberts AC, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics 2009;123(4):1184-1190.
25. Fontan Jean-Eudes. Medication errors in hospital: computerized unit dose drug dispensing system versus ward stock distribution system. Pharmacy World and Science 2003;25(3): 112-117.
26. Durieux P, Trinquart L, Colombet I, Niès J, Walton R, Rajeswaran A, Burnand B. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2008;3.
27. Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatric critical care medicine 2011;12(3):304-308.
28. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, Gawande AA. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009;360(5):491-499.
29. Pikkel D, Sharabi-Nov A, Pikkel J. The importance of side marking in preventing surgical site errors. The International Journal of Risk and Safety in Medicine 2014;26(3):133-138.
30. Evans SM. Attitudes and barriers to incident reporting: a collaborative hospital study.Quality and Safety in Health Care 2006;15(1):39-43.
31. Benn J, Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care 2009;18(1):11-21.
32. McFadden KL, Stock GN, Gowen III CR. Leadership, safety climate, and continuous quality improvement: Impact on process quality and patient safety. Health care management review 2014.
33. Despins Laurel A. Patient safety and collaboration of the intensive care unit team. Critical care nurse 2009;29(2):85-91.
34. Papaspyros SC, Javangula KC, Adluri RKP, O'Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interactive cardiovascular and thoracic surgery 2010;10(1):43-47.