scholarly journals Slips, lapses and mistakes inthe use of equipment by nurses in an intensive care unit

2016 ◽  
Vol 50 (3) ◽  
pp. 419-426 ◽  
Author(s):  
Gabriella da Silva Rangel Ribeiro ◽  
Rafael Celestino da Silva ◽  
Márcia de Assunção Ferreira ◽  
Grazielle Rezende da Silva
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Human Error ◽  
Work Process ◽  
Infusion Pumps ◽  
Memory And Attention ◽  
Compromise Patient Safety ◽  
The City ◽  
Error Method

Abstract OBJECTIVE Toidentify the occurrence of errors in the use of equipment by nurses working in intensive careandanalyzing them in the framework of James Reason's theory of human error. METHOD Qualitative field study in the intensive care unit of a federal hospital in the city of Rio de Janeiro. Observation and interviews were conductedwith eight nurses, from March to December 2014. Content analysis was used for the interviews, as well as the description of the scenes observed. RESULTS Lapses of memory and attention were identified in the handling of infusion pumps, as well as planning failures during the programming of monitors. CONCLUSION Errors cause adverse events that compromise patient safety. The authors propose creation of an instrument for daily checking of equipment, with checks throughout the work process in the programming of infusion pumps and monitors, in order to reduce failures and memory lapses.

scholarly journals Reducing errors in the administration of medication with infusion pumps in the intensive care department: A lean approach

2019 ◽  
Vol 7 ◽  
pp. 205031211882262
Author(s):  
Alexander F van der Sluijs ◽  
Eline R van Slobbe-Bijlsma ◽  
Astrid Goossens ◽  
Alexander PJ Vlaar ◽  
Dave A Dongelmans
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Confidence Interval ◽  
Medication Errors ◽  
Infusion Pump ◽  
Baseline Measurement ◽  
Infusion Pumps ◽  
Improvement Measures ◽  
The Impact

Background: Medication errors occur frequently and may potentially harm patients. Administering medication with infusion pumps carries specific risks, which lead to incidents that affect patient safety. Objective: Since previous attempts to reduce medication errors with infusion pumps failed in our intensive care unit, we chose the Lean approach to accomplish a 50% reduction of administration errors in 6 months. Besides improving quality of care and patient safety, we wanted to determine the effectiveness of Lean in healthcare. Methods: We conducted a before-and-after observational study. After baseline measurement, a value stream map (a detailed process description, used in Lean) was made to identify important underlying causes of medication errors. These causes were discussed with intensive care unit staff during frequent stand-up sessions, resulting in small improvement cycles and bottom-up defined improvement measures. Pre-intervention and post-intervention measurements were performed to determine the impact of the improvement measures. Infusion pump syringes and related administration errors were measured during unannounced sequential audits. Results: Including the baseline measurement, 1748 syringes were examined. The percentage of errors concerning the administration of medication by infusion pumps decreased from 17.7% (95% confidence interval, 13.7–22.4; 55 errors in 310 syringes) to 2.3% (95% confidence interval, 1–4.6; 7 errors in 307 syringes) in 18 months (p < 0.0001). Conclusion and Relevance: The Lean approach proved to be helpful in reducing errors in the administration of medication with infusion pumps in a high complex intensive care environment.

Impact of implementing smart infusion pumps in a pediatric intensive care unit

2013 ◽  
Vol 70 (21) ◽  
pp. 1897-1906 ◽  
Author(s):  
Silvia Manrique-Rodríguez ◽  
Amelia C. Sánchez-Galindo ◽  
Jesús López-Herce ◽  
Miguel Ángel Calleja-Hernández ◽  
Fernando Martínez-Martínez ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Pediatric Intensive Care Unit ◽  
Pediatric Intensive Care ◽  
Infusion Pumps ◽  
Systematic Analysis ◽  
The Impact ◽  
Smart Pump ◽  
Programming Errors

Abstract Purpose The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated. Methods A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010–June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed. Results During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases. Conclusion The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.

scholarly journals Nursing Activities Score by assistance sites in Intensive Care Units

2017 ◽  
Vol 22 (1) ◽  
Author(s):  
Claudia Maria Silva Cyrino ◽  
Magda Cristina Queiroz Dell'Acqua ◽  
Meire Cristina Novelli e Castro ◽  
Elaine Machado de Oliveira ◽  
Sérgio Deodato ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Retrospective Study ◽  
Confidence Interval ◽  
Clinical Characteristics ◽  
Surgical Patients ◽  
Nursing Workload ◽  
Work Process ◽  
Nursing Team

Abstract Objective: To compare the Nursing Activities Score (NAS) between the Assistance Sites in an Intensive Care Unit. Method: Descriptive, retrospective study, carried out in the Intensive Care Unit of a teaching hospital. The patients were organized in Assistance Sites according to their clinical characteristics and the nursing team's composition was organized in accordance with the Nursing Activities Score (NAS). The confidence interval was set at p < 0.05. Results: the majority were male surgical patients with a mean age of 56.8 years. The postoperative care Site presented the greatest patient turnover. The overall average NAS was 71.7%. There was a difference in the nursing workload between the different Assistance Sites. The shorter length of stay and the nonsurvivors contributed to increasing the workload in the ICU. Conclusion: Comparing the NAS in the different Sites made it possible to organize the work process of the nursing team according to each group, contributing to patient safety.

The frequency and impact of task interruptions in the ICU

2007 ◽  
Vol 51 (11) ◽  
pp. 683-686 ◽  
Author(s):  
Frank A. Drews
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Observational Data ◽  
Conditional Probability ◽  
Human Error ◽  
Negative Impact ◽  
Epidemiological Studies ◽  
Primary Task ◽  
Contributing Factors

Up to 98,000 patients die annually in U.S. hospitals due to human error. Despite epidemiological studies demonstrating the severity of this problem it is still unclear what the contributing factors to human error are. However, in aviation one contributor to accidents is task interruptions. The present study examined the frequency and impact of task interruptions in the Intensive Care Unit. Observational data were collected in the ICU by shadowing nurses. During the 34 hours of observation, 1138 nurse activities were observed, of which 29.4% were interrupted. Consequences of an interruption for the primary task can be abandoning its completion or omissions of some of the tasks steps. The conditional probability that an interrupted task was abandoned was p(abandoned | interrupted) = .12, where the omission of steps of the primary task had a conditional probability of p(omission | interrupted) = .015. A total of six cases that created patient hazards were observed where in five of these cases an interruption preceded directly. The results of the present study indicate that interruptions in the ICU are frequent and are likely to have a negative impact on patient safety.

Atmung – Standardisierte Checkliste macht Intubation von Neugeborenen sicherer

2017 ◽  
Vol 22 (03) ◽  
pp. 124-125
Author(s):  
Maria Weiß
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Improve Patient Safety ◽  
Improve Patient

Hatch LD. et al. Intervention To Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. Pediatrics 2016; 138: e20160069 Kinder auf der Neugeborenen-Intensivstation sind besonders durch Komplikationen während des Krankenhausaufenthaltes gefährdet. Dies gilt auch für die Intubation, die relativ häufig mit unerwünschten Ereignissen einhergeht. US-amerikanische Neonatologen haben jetzt untersucht, durch welche Maßnahmen sich die Komplikationsrate bei Intubationen in ihrem Perinatal- Zentrum senken lässt.

scholarly journals Emergence of Candida auris in Brazil in a COVID-19 Intensive Care Unit

2021 ◽  
Vol 7 (3) ◽  
pp. 220
Author(s):  
João N. de Almeida ◽  
Elaine C. Francisco ◽  
Ferry Hagen ◽  
Igor Brandão ◽  
Felicidade M. Pereira ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Antifungal Susceptibility ◽  
Candida Auris ◽  
Minimal Inhibitory Concentrations ◽  
First Case ◽  
Asian Clade ◽  
Travel Restrictions ◽  
Clade C ◽  
The City

In December 2020, Candida auris emerged in Brazil in the city of Salvador. The first two C. auris colonized patients were in the same COVID-19 intensive care unit. Antifungal susceptibility testing showed low minimal inhibitory concentrations of 1 µg/mL, 2 µg/mL, 0.03 µg/L, and 0.06 µg/mL for amphotericin B, fluconazole, voriconazole, and anidulafungin, respectively. Microsatellite typing revealed that the strains are clonal and belong to the South Asian clade C. auris. The travel restrictions during the COVID-19 pandemic and the absence of travel history among the colonized patients lead to the hypothesis that this species was introduced several months before the recognition of the first case and/or emerged locally in the coastline Salvador area.

scholarly journals The role of the nurse in the neonatal intensive care unit: between the ideal, the real and the possible

2011 ◽  
Vol 19 (2) ◽  
pp. 301-308 ◽  
Author(s):  
Liciane Langona Montanholi ◽  
Miriam Aparecida Barbosa Merighi ◽  
Maria Cristina Pinto de Jesus
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Public And Private ◽  
Public And Private Hospitals ◽  
The City ◽  
Social Phenomenology ◽  
The Ideal

The nurse is one of the professionals responsible for the care directed toward the physical, mental and social development of newborns in the Neonatal Intensive Care Unit. This study aimed to comprehend the experience of nurses working in a Neonatal Intensive Care Unit. Data collection was performed in 2008, through interviews with 12 nurses working in public and private hospitals of the city of São Paulo. The units of meaning identified were grouped into three categories: Developing actions; Perceiving their actions and Expectations. The analysis was based on social phenomenology. It was concluded that the overload of activities, the reduced number of staff, the lack of materials, equipment and the need for professional improvement are the reality of the work of the nurse in this sector. To supervise the care is the possible; integral care of the newborn, involving the parents, is the ideal desired.

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