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

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.