NURSI NG FAULTS I N THE RECOVERY PERI OD OF SURGI CAL PATI ENTS
Tânia Cout o Machado Chianca1
Ch ian ca TCM. Nu r sin g f au lt s in t h e r ecov er y p er iod of su r g ical p at ien t s. Rev Lat in o- am En f er m ag em 2 0 0 6
n ov em b r o- d ezem b r o; 1 4 ( 6 ) : 8 7 9 - 8 6 .
This is a descr ipt ive st udy based on t he t heor y of hum an er r or , in or der t o analyze and classify nur sing
er r or s dur ing t he nur sing car e of sur gical pat ient s at r ecov er y . Tw ent y - fiv e ( 2 5 ) fault r epor t s w er e collect ed
t hr ough a sem i- st r uct ur ed int er view . Those r epor t s w er e subm it t ed t o 15 nur se exper t s t o evaluat e t he r isk of
ser iou sn ess; h u m an , equ ipm en t an d or gan izat ion al f act or s in v olv ed; m em ber s in t er act ion ; in f or m at ion an d
r ever sibilit y of t he accident . Fault s w er e dir ect ly at t r ibut ed t o psychosocial and or ganizat ional aspect s, equipm ent
and ser iousness. A m ult idim ensional scaling t est ( MDS) w as applied and a gr aph w as obt ained. I t show ed four
gr oups of fault s, due t o pr oblem s r elat ed t o sensor y - m ot or , pr ocedur e, abst r act ion and super v ision cont r ol. I n
con clu sion , t h e f au lt s w er e cau sed b y n on d ef in ed p er son n el r oles, con t in u in g ed u cat ion d ef icien cy , n on
-sy st em at ic obser v at ion , in adequ at e space an d equ ipm en t .
DESCRI PTORS: post oper at iv e car e/ n u r sin g; iat r ogen ic disease; h ealt h facilit ies
LAS FALLAS DE EN FERMERÍ A EN EL PERI ODO DE RECUPERACI ÓN DE PACI EN TES
QUI RÚRGI COS
Est udio descr ipt iv o- ex plor at or io, fundam ent ado en la Teor ía del Er r or Hum ano, con obj et o de analizar
y clasificar fallas de enfer m er ía dur ant e la at ención a pacient es en el post oper at or io inm ediat o. A t r av és de
ent r evist a sem iest r uct ur ada, fuer on r ecopilados 25 r elat os de fallas, som et idos a la evaluación de 15 enfer m er os
esp eci al i st as co n r esp ect o a 7 v ar i ab l es. Est as f u er o n r ed u ci d as a asp ect o s p si co so ci al es/ eq u i p am i en t o ,
or g an izacion ales y g r av ed ad m ed ian t e el an álisis d e com p on en t es p r in cip ales. Fu e r ealizad o u n t est e d e
escal o n am i en t o m u l t i d i m en si o n al ( MDS) , r esu l t an d o en u n g r áf i co co n 4 g r u p o s d e f al l as. Est o s f u er o n
int er pr et ados com o siendo al nivel sensor io- m ot or , de pr ocedim ient o, de abst r acción y de cont r ol de super visión.
Las f al l as f u er o n cau sad as p o r i n d ef i n i ci ó n d e p ap el , cap aci t aci ó n d ef i ci en t e, o b ser v aci ó n asi st em át i co ,
in adecu ación física y de equ ipam ien t os.
DESCRI PTORES: cu idados post oper at or ios/ en f er m er ía; en f er m edad iat r ogén ica; in st it u cion es de salu d
FALHAS DE ENFERMAGEM NO PÓS- OPERATÓRI O I MEDI ATO DE PACI ENTES CI RÚRGI COS
Est u do descr it iv o- ex plor at ór io, f u n dam en t ado n a Teor ia do Er r o Hu m an o, par a an alisar e classif icar
f alh as de en f er m agem du r an t e a assist ên cia a pacien t es em pós- oper at ór io im ediat o. At r av és de en t r ev ist a
sem i - est r u t u r ad a col et ou - se 2 5 r el at os d e f al h as q u e f or am su b m et i d os à av al i ação p or 1 5 en f er m ei r os
especialist as quant o a 7 var iáveis. Essas for am r eduzidas a aspect os psicossociais/ equipam ent o, or ganizacionais
e g r av id ad e p ela an álise d e com p on en t es p r in cip ais. Realizou - se t est e d e escalon am en t o m u lt id im en sion al
( MDS) e obt eve- se gr áfico m ost r ando 4 gr upos de falhas, que for am int er pr et ados com o sendo no nível sensór
io-m ot or , de pr ocediio-m ent o, de abst r ação e de cont r ole de super v isão. As falhas for aio-m causadas por indefinição
de papel, t r ein am en t o deficien t e, obser v ação assist em át ica, in adequ ação física e de equ ipam en t os.
DESCRI TORES: cu idados pós oper at ór ios/ en fer m agem ; doen ça iat r ogên ica; in st it u ições de saú de
1 Assist ant Pr ofessor, Minas Gerais Federal Univer sit y College of Nur sing, e- m ail: t chianca@enf.ufm g.br
I NTRODUCTI ON
T
his st udy w as based on our concer n about n u r s i n g c a r e f o r p a t i e n t s d u r i n g t h e i m m e d i a t ep ost op er at iv e p er iod in Br azilian h osp it als, m ost of
w h ich d o n ot of f er p ost - an est h esia r ecov er y ( PAR)
unit s t hat ar e pr oper ly equipped, funct ioning, w it h a
su f f i ci en t n u m b er o f q u al i t at i v el y t r ai n ed st af f f o r
sy st em ized high- qualit y car e deliv er y t o pat ient s. We
b eliev e t h at ad v er se sit u at ion s d u r in g n u r sin g car e
d eliv er y t o PAR p at ien t s in cr ease er r or p ossib ilit ies
a n d d e cr e a se t h e sy st e m ’ s r e l i a b i l i t y ; t h e t e a m
w o r k i n g i n t h e PAR r o o m i s r e sp o n si b l e f o r t h e
ad eq u at e h an d lin g of eq u ip m en t an d m at er ial; t h e
d ef in it ion of t ask s an d f u n ct ion s an d t h e r elat ion s
bet w een t eam m em ber s in t er f er e in t h e occu r r en ce
of hum an er r or s; access t o infor m at ion and know ledge
can d ecr ease t h eir occu r r en ce; an d sim ilar cen t r al
com p on en t s can b e d et ect ed in ap p ar en t ly d ist in ct
er r o r s.
I n t his st udy, w e aim t o cont r ibut e t o a m or e
q u al i f i ed car e d el i v er y, w i t h r ed u ced h u m an er r o r
r i sk s. Th u s, w e d e ci d e d t o t e st t h e h u m a n e r r o r
r ef er en ce f r am ew or k in p er iop er at iv e n u r sin g car e
( m o r e p r e ci se l y i n t h e i m m e d i a t e p o st o p e r a t i v e
p e r i o d ) , w h i c h w a s p r o p o s e d b y e n g i n e e r s ,
phy siologist s and cognit iv e psy chologist s t o im pr ov e
t h e r eliabilit y of h u m an ex ecu t ion( 1 ), in t h is case in
t h e per ioper at iv e n u r sin g ar ea.
Sit u at ion s in v olv in g h u m an oper at or s ar e a
com m on t hem e in er gonom ics, cov er ing hum an er r or
am on g ot h er asp ect s( 2 ). I n t h is st u d y, w e u se t h e
c o n c e p t u a l m o d e l b y Ja m e s Re a s o n( 3 ), w h i c h
est ab lish es t h e or ig in s of b asic h u m an er r or t y p es
a n d t h e g e n e r i c e r r o r s t r u c t u r e s y s t e m , l a r g e l y
der iv ed fr om t h e h u m an act ion classificat ion by Jen
Rasm ussen ( sk ill- r ule- k now ledge) . The sy st em allow s
for t hr ee basic er r or t ypes: skill ( m ist akes and slips) ;
r ule and k now ledge ( er r or s in t heir t r ue sense) .
Th e b e h a v i o r b a se d o n t h e l e v e l o f sk i l l s
cor r esponds t o t he sensor y- m ot or per for m ance dur ing
a ct i o n s o r a ct i v i t i e s w h i ch , a f t e r f o r m u l a t i n g t h e
int ent ion, act s w it hout conscious cont rol ( disent angled,
au t om at ed an d in t egr at ed beh av ior s) . Er r or s at t h is
l e v e l a r e r e l a t e d t o c h a n g e s i n t h e l e v e l o f
coor dinat ion, space or t im e( 3).
Behav ior s based on r ule and k now ledge, on
t h e o t h er h a n d , a r e a ssu m ed a f t er t h e i n d i v i d u a l
becom es aw ar e of a pr oblem . The r ule- based level is
t he connect ion bet w een fam ily pr oblem s and alr eady
est ab lish ed solu t ion s t h r ou g h t h e st an d ar d s. Er r or s
ar e r elat ed t o t he w r ong applicat ion of t he st andar d
or m ist ak en m em or ies abou t t h e pr ocedu r es.
At t h e k n ow ledge- based per f or m an ce lev el,
er r or s ar e r elat ed t o appr opr iat e t ask select ion an d
lim it at ions in t he w ork environm ent . At t his level, w hen
t he indiv idual is confr ont ed w it h unk now n sit uat ions,
act ion s m u st b e p lan n ed w it h t h e h elp of an aly t ic
p r ocesses an d alr ead y acq u ir ed k n ow led g e. Er r or s
e m e r g e f r o m l i m i t a t i o n s i n m a t e r i a l r e so u r ce s o r
t hr ough t he r at ional pr ocess t hat inv olv es insufficient
or incor r ect k now ledge. The t hr ee lev els can coex ist .
Er r or s ar e closely connect ed w it h t he not ion
o f i n t e n t( 3 ) a n d a ct i o n s l e a d i n g t o e r r o r s ca n b e
i n t e n t i o n a l o r i n v o l u n t a r y ( n o n - i n t e n t i o n a l ) .
I n v olu n t ar y act ion s n or m ally d er iv e f r om m om en t s
o f l ack o f car e, w h en w e b eco m e aw ar e t h at o u r
a c t i o n s d e v i a t e d f r o m o u r i n t e n t . Th e s e a c t i o n
m ist a k e s occur w hen w e per for m highly aut om at ed
t ask s, in v er y fam iliar env ir on m ent s.
S l i p s a r e h i d d e n , u n i n t e n t i o n a l f o r m s o f
er r or s, gen er ally in v olv in g m em or y f ailu r es t h at do
not necessarily m anifest t hem selves in act ual behavior.
Wh en act ion s ar e in t en t ion al an d occu r as
planned, t hey can st ill be w r ong if t hey do not r each
t h e ex p ect ed ob j ect iv e. I n t h is case, t h e p lan m ay
not be adequat e, leading t o so- called e r r or s. These
er r or s ar e g en er ally r elat ed t o in d iv id u als’ lack of
ex per ience w ho, based on ear lier ex per iences, m ak e
in cor r ect an alogies( 4 ).
I n B r a z i l i a n n u r s i n g , s t u d i e s h a v e b e e n
developed about m edicat ion er r or s( 5- 6), but w e ar e not
aw ar e of any st udies t hat hav e classified, quant ified,
t y pified or an aly zed er r or s in ot h er h ealt h ar eas, in
an at t em pt t o under st and and pr edict t hem and cr eat e
pr ev en t ion st r at egies.
Th e su r g i ca l ce n t e r i s a so ci o t e ch n i ca l
-st r uct ur ed sy -st em( 7), aim ed at deliv er ing pat ient car e
dur ing t he pr e- , t r ans- and im m ediat e post oper at iv e
per iods, and effor t s should be m ade t o incr ease t he
sy st em ’s pr obabilit y of su ccess, it s r eliabilit y, w h ich
is closely r elat ed w it h t he cont r ol of hum an m ist akes
in act ivit ies, as w ell as w it h t he cont rol of m ist akes in
t he equipm ent and sur gical env ir onm ent . These m ay
cr eat e behavior s t hat lead t o insecur it y in t he syst em .
Th i s st u d y a i m e d t o a n a l y ze a n d cl a ssi f y
er r or s com m it t ed by t he nur sing t eam in pat ient car e
MATERI AL AND METHOD
Wr ong behavior s and at t it udes can be st udies
w it h t h e h elp of st at ist ical, ep id em iolog ical or case
an aly sis m et h od s. Var iou s p r of ession als h av e u sed
m ult ivariat e st at ist ical t echniques t o group dat a. When
confr ont ed w it h subj ect ive var iables, w hich supposedly
ex ist w h en m ist ak es ar e com m it t ed, w e in qu ir e, for
ex am ple, about t he r elev ant fact or s ar e t o analy ze a
h u m an er r or. Wh at ar e it s cau ses? Th e an sw er s t o
t h ese q u est ion s can b e d iscov er ed b y con st r u ct in g
obj ect iv e scales, obt ain ed t h r ou gh m u lt iv ar iat e dat a
and analyzed per fact or or on t he basis of dat a about
dissim ilar it ies, u sin g m u lt idim ension al scalin g ( MDS)
t o int er pr et t hem .
I n t h i s st u d y, w e d eci d ed t o co n st r u ct an
o b j e c t i v e s c a l e o f s u b j e c t i v e a t t r i b u t e s , u s i n g
S t a t i s t i c a l Pr o g r a m f o r S o c i a l S c i e n c e s ( S PS S )
soft w ar e t o an aly ze t h e dist an ce bet w een dat a t h at
i n d i cat e t h e d eg r ee o f d i ssi m i l ar i t y ( o r si m i l ar i t y )
bet w een t w o t hings( 8).
Th e st u d y w as au t h or ized b y t h e Resear ch
Et h ics Com m ission at t h e Clin ical Hospit al of Min as
Ger ais Feder al Un iv er sit y an d by t h e boar ds of t h e
inv olv ed univ er sit ies. All nur sing t eam m em ber s and
ex per t s signed an infor m ed consent t er m .
St u dy par t icipan t s
As w e int ended t o collect infor m at ion about
m ist ak es occu r r ed d u r in g im m ed iat e p ost op er at iv e
p a t i e n t c a r e , w e r e q u e s t e d r e p o r t s o n r e l e v a n t
m ist ak es, in w h ich t h e car egiv er ’s beh av ior en t ailed
negat iv e consequences for his/ her obj ect iv e. For t his
purpose, w e used t he Cr it ical I ncident Technique( 9) as
a r efer en ce t o obt ain n egat iv e in ciden t s, ask in g t h e
f ollow in g qu est ion , w h ose con t en t w as v alidat ed by
n u r si n g ex p er t s: t h i n k ab o u t o n e o ccasi o n d u r i n g
w hich you w it nessed or par t icipat ed in a fault or hum an
er r or d u r in g im m ed iat e p ost op er at iv e p at ien t car e
deliv er y. Descr ibe w hat happened, t he sit uat ion, t he
t ype of pat ient , t he sur ger y, w hat t he per son did and
w hat t he consequences of t he er r or / fault w er e.
Ou r sam p le con sist ed of f au lt r ep or t s t h at
w er e con sid er ed v alid , com p let e, clear an d p r ecise
and w er e collect ed fr om nur sing t eam m em ber s w ho
w or k ed at su r gical cen t er u n it s an d post - an est h esia
r ecover y r oom s ( PAR) of t en m edium and lar ge- sized
hospit als in Belo Hor izont e, based on sem ist r uct ur ed
in t er v iew s.
I nit ially, w e collect ed 31 fault r epor t s, 25 of
w hich could be used. The r em aining six r epor t s w er e
w i t h d r a w n b e ca u se co n t e n t s w e r e r e p e a t e d a n d
becau se t h ey w er e in com plet e ( con t ain in g sit u at ion ,
behavior s and consequences) . A t it le and abbr eviat ion
( 1 0 )
w er e at t r ibu t ed t o each r epor t , as illu st r at ed by
t h e ex am ple below .
O v e r d o si s( o v e r ) - Pat ien t d u r in g im m ed iat e
post operat ive period aft er ost eot om y of t he right t ibia, high blood
pr essur e, t aking Adalat on a r egular basis and com plaining of
pain. The pat ient r eceived an int r avenous analgesic and, soon
aft er w ar ds, t he nur sing auxiliar y adm inist er ed a new dose of
I sordil, t alking w it h anot her colleague w hile she delivered care t o
t he pat ient . Aft er r eceiving t he t w o dr ugs, t he pat ient ’s blood
pr essur e, init ially at 130 x 80 m m Hg, changed t o 90 x 60 m m Hg.
The pat ient got hypot ension as a result of t he int eract ion bet ween
t he t w o dr ugs, as bot h ar e hypot ensive agent s. Blood pr essur e
w as ver ified fr equent ly unt il st abilizing at 120 x 70 m m Hg.
I n st r u m en t elabor at ion an d er r or r epor t assessm en t
p r o ced u r es
We elabor at ed an in st r u m en t t o be applied
am on g ex per t s, w h o h ad t o j u dge t h e r epor t s w it h
r espect t o t h e f ollow in g v ar iables: sev er it y ; degr ee
o f f o r e s e e a b i l i t y ; h u m a n , e q u i p m e n t a n d
or ganizat ional fact or s; group r elat ions and infor m at ion.
These variables w ere chosen t o cover t he flaw in it self,
a s w e l l a s p e r s o n a l , s o c i a l , o r g a n i z a t i o n a l a n d
equipm ent aspect s. We defined t he var iables t hat w e
con sider t o be in v olv ed in im m ediat e post oper at iv e
nur sing car e and elabor at ed a fiv e- point Lik er t scale
for each var iable. The inst r um ent w as t est ed in a gr oup
o f t h r e e f a cu l t y - r e se a r ch e r s, o n e n u r se a n d t w o
occupat ional psychologist s. Aft er t heir suggest ions had
b een in cor p or at ed , t h e in st r u m en t w as con sid er ed
good, fav or ing t he t y pificat ion of nur sing er r or s( 10).
Each j udge r eceived 25 pages, each of w hich
cont ained one r epor t , w it h scales t o m ake r ecor ds on
each of t h e sev en v ar iab les. For each v ar iab le, an
explanat ion w as given and t he exper t had t o gr ant a
scor e t o t he fact or ’s r ole in each fault . The pr ov ided
scores w ere calculat ed and t he m edian values for each
r epor t w er e ent er ed int o a m at r ix .
Fift een exper t s collabor at ed, including nur ses,
w ho w ere specialized in surgical cent er and im m ediat e
post oper at iv e pat ien t car e. Ex per t s w er e ch osen at
r a n d o m . We l o o k e d f o r c h a r a c t e r i s t i c s l i k e
p r of ession al ex p er ien ce at a Su r g ical Cen t er Un it ,
i n cl u d i n g i m m e d i a t e p o st o p e r a t i v e p a t i e n t ca r e ,
Dat a t r eat m ent and analy sis
We o b t ai n ed 2 5 f au l t r ep o r t s, w h i ch w er e
an aly zed by 1 5 j u dges in t er m s of sev en v ar iables,
w ho consider ed five degr ees, t ot aling 2,625 evaluat ion
scor es. Joining t he 15 j udges’ m edian scor es for each
fault r epor t , w e const r uct ed a m at r ix w it h 175 m edian
values. Fift y per cent of j udgm ent s w er e concent r at ed
eit her abov e or below t hese.
N e x t , w e a p p l i e d Pr i n c i p a l Co m p o n e n t s
An a l y s i s ( PCA) a n d , i n c h o o s i n g t h e n u m b e r o f
c o m p o n e n t s , w e c o n s i d e r e d t h e e s t a b l i s h e d
crit erion( 11), t hat is, lat ent root s higher t han one. This
a l l o w e d u s t o i s o l a t e t h r e e o r t h o g o n a l f a c t o r s ,
cor r esponding t o 67% of t ot al v ar iance, w it h a v iew
t o obt aining significant and non- cor r elat ed com ponent s
fr om a t heor et ical point of v iew . PCA is a v ar iant of
f a ct o r i a l a n a l y si s, u se d t o r e d u ce t h e n u m b e r o f
var iables cor r elat ed by a sm all num ber of independent
v ar i ab l es.
Af t er ex t r act in g t h e m ain ax es, t h ese w er e
su b m i t t ed t o o r t h o g o n a l r o t a t i o n , u si n g t h e m o st
popular pr ocedur e, w hich is t he v ar im ax m et hod( 1 2 ).
I n t h i s p r o c e d u r e , n e w c o o r d i n a t e ( p r i n c i p a l
com ponent ) axes cross one anot her. This im plies t hat
d i f f e r e n t p r i n ci p a l co m p o n e n t s a r e i n d e p e n d e n t ,
w it hout any m ut ual r elat ion.
PCA alone does not t ell us w hat w e w ill find
in concept ual t er m s. Thus, it w as com plem ent ed w it h
m u l t i d i m en si o n a l sca l i n g ( MD S) , so a s t o f i n d a n
a d e q u a t e g r a p h i c a r r a n g e m e n t f o r t h e n u r s i n g
m ist ak es and allow for m ut ual com par isons.
We used t he sim plest MDS m odel t o obt ain a
classical dissim ilar it y m at r ix . Dat a w er e sy m m et r ical
and t he t w o- dim ensional Euclidian m odel could be used
f o r t h e m a t r i x . Th e co o r d i n a t e s o u t l i n e d b y t h e
com p u t er p r og r am g en er ally ar e n ot su scep t ib le t o
dir ect obser vat ion, but can be sket ched r andom ly and
t h e d ir ect ion s t ak en in t h e MDS con f ig u r at ion can
pr ov ide int er est ing aspect s for int er pr et at ion.
RESULTS
Eig h t y p er cen t of t h e t en h osp it als in Belo
Hor izon t e - MG, w h er e t h e r ep or t s w er e collect ed ,
o f f e r e d a PA R v e n u e . O n l y 2 0 % o f t h e s e u s e d
ap p r op r iat e b ed s. I n t h e r em ain d er, p at ien t s w er e
p laced in b ed s w it h b ar s; 7 0 % h ad an em er g en cy
car t w it h a h ear t d ef ib r illat or. I n 5 0 % of t h e PAR,
oxygen and vacuum exit s w er e channeled per bed. I t
should be highlight ed t hat , in all hospit als w it h a PAR
venue, nursing auxiliaries offered pat ient care, w it hout
t he pr esence of a nur se.
Th e ex p er t s co n si d er ed t h e o r g an i zat i o n al
fact or as t ot ally or quit e det er m inant of m ist ak es in
2 4 ( 9 6 % ) r epor t s. Gr ou p r elat ion s play ed a ( t ot ally
or quit e) det er m inant r ole in 14 ( 56% ) r epor t s. The
infor m at ion fact or w as consider ed t o be t ot ally or quit e
d et er m in an t in 2 0 ( 8 0 % ) m ist ak es an d t h e h u m an
f act or in 2 4 ( 9 6 % ) . Th e eq u ip m en t f act or w as n ot
det er m inant in 19 ( 76% ) m ist ak es.
As t o t h e d e g r e e o f f o r e se e a b i l i t y, m o st
e x p e r t s co n si d e r e d n o n e o f t h e f a u l t r e p o r t s a s
u n f or eseeable. Th ey con sider ed 1 8 ( 7 2 % ) er r or s as
t o t al l y o r q u i t e f o r eseeab l e. As t o t h e sev er i t y o f
m ist akes, t he exper t s j udged t hat four ( 16% ) m ist akes
could have led t o t he pat ient ’s deat h; 5 ( 20% ) could
h a v e d e t e r m i n e d a p e r m a n e n t l i m b o r f u n c t i o n
defor m it y, loss or uselessness or ir r em ediable m or al
dam age; t em por ar y lim b, con sciou sn ess or f u n ct ion
w eakness in 11 ( 44% ) m ist akes; dam age t o physical,
m en t al or m or al in t egr it y w it h ou t cau sin g w eak n ess
in 5 ( 20% ) fault r epor t s. None of t he m ist akes under
analy sis w as consider ed as hav ing lit t le possibilit y of
d am ag i n g t h e p at i en t ’ s p h y si cal , m en t al o r m o r al
in t egr it y.
Based on t h e ob t ain ed m ed ian v alu es an d
a p p l y i n g PCA a f t e r r o t a t i o n t h r o u g h t h e v a r i m a x
m et h od , w e cou ld isolat e t h r ee or t h og on al f act or s,
i.e. com ponent s I , I I and I I I . The com ponent s’ fact or ial
loads ar e pr esent ed in Table 1. Com ponent I , called
p sy ch o so ci al an d eq u i p m en t asp ect s, co v er ed t h e
f ollow in g v ar iab les: h u m an f act or, in f or m at ion an d
gr ou p r elat ion s. Wh en apply in g PCA, t h e equ ipm en t
fact or ( w it h a high negat ive individual fact orial load
-.63) w as also gr ouped in com ponent I . How ev er, t he
e q u i p m e n t f a ct o r i s o p p o se d t o t h e o t h e r t h r e e
v ar iab les b ecau se it is con cep t u ally d if f er en t f r om
psychosocial aspect s, and is t herefore called a bipolar
co m p o n e n t . I t i s b i p o l a r b e ca u se i t i m p l i e s t h a t
psy ch osocial aspect s ar e opposed t o t h e equ ipm en t
fact or. A low scor e on t his com ponent im plies t hat an
equipm ent fault pr evailed in t he fault r epor t s, w hile a
h igh scor e in dicat es t h e pr ev alen ce of psy ch osocial
aspect s in t he fault .
Co m p o n e n t I I w a s c a l l e d o r g a n i z a t i o n a l
aspect s. This com ponent is also called bipolar because
it im plies t hat t he or ganizat ional fact or is opposed t o
for eseeabilit y and t he or ganizat ional fact or hav e high
indiv idual fact or ial loads, t he for m er w it h a negat iv e
( - . 83) and t he lat t er w it h a posit iv e load ( . 78) . This
m ean s t h at or g an izat ion al cau ses p r ev ail ov er t h e
m i s t a k e s ’ d e g r e e o f f o r e s e e a b i l i t y. Th e m o r e
or ganizat ional t he causes of m ist ak es ar e, t he low er
t heir degr ee of for eseeabilit y w ill be.
Table 1- St r uct ur e of nur sing fault com ponent s
r e l a t i o n s w e r e q u i t e d e t e r m i n i n g . Th e e q u i p m e n t
f a c t o r d i d n o t p l a y a d e t e r m i n i n g r o l e i n t h e s e
m ist ak es. I n t h e t h r ee r ep or t s, t h e m ist ak es w er e
c o n s i d e r e d a s t o t a l l y f o r e s e e a b l e a n d c a u s i n g
t em por ar y lim b, consciousness or funct ion w eak ness.
The fault r epor t s called CORTE, DRENO and
OVERDOSI S ( OVER) p r esen t ed d if f er en ces in m ean
values am ong alm ost all variables, alt hough t he st im uli
coor din at or s in dim en sion s 1 an d 2 , u sed t o cr eat e
t he MDS gr aph, ar e pr act ically t he sam e, ( CORTE=
-0 . 4 5 1 -0 an d -0 . 4 1 2 7 ; DRENO= - -0 . 4 5 1 -0 an d -0 . 4 1 2 7 ;
OVER= - 0.4507 and 0.4108) , appr ox im at ing t hem in
t er m s of sim ilar it y.
Th e st i m u l i coor d i n at es f or t h e f au l t p ai r s
called SOLI TUDE ( SOLI ) and PI ECE ( PECA) r epr esent
t h e m u t u a l l y m o s t d i s t a n t n u m b e r i n t h e t w o
dim ensions ( SOLI TUDE= 2. 1105 and 1. 0196; PECA=
- 1.7471 and - 0.1282) . I n Figur e 1, t hey ar e show n in
t he upper left and low er r ight angle ( dr aw ing im aginar y
lines on t he 0, 0 ax is) . These m ist ak es ar e t he m ost
dist ant , t hat is, t he differ ences bet w een t hem ar e t he
g r eat est . Th er ef or e, t h e set of r ep or t s - COMMENT
( COMT) , EXCHANGE ( TRO) , TRANSFI X ( TRAF) , HI T
( PANC) and PI ECE ( PECA) - locat ed on t he left in t he
g r ap h , ar e m o st d i f f er en t f r o m t h e set o f r ep o r t s
S OLI TUD E ( S OLI ) , S ECRETI ON ( S ECR) , LA RYN X
( LARI N) and OMI SSI ON ( OMI ) , locat ed on t he r ight in
t he gr aph. s
e l b a i r a
V Components
I II III
r o t c a f n a m u
H .80* .22 .16
n o i t a m r o f n
I .78* -.23 -.12
r o t c a f t n e m p i u q
E -.63* .18 .39
s n o i t a l e r p u o r
G .61* .35 13
y t il i b a e e s e r o f f o e e r g e
D .04 -.83* -.03
r o t c a f l a n o i t a z i n a g r
O .08 .78* -.09
y t i r e v e
S .02 -.09 .92*
* Fact or ial load ( > .35) consider ed t o int er pr et fact or s
Com ponent I I I cor r esponds t o er r or sev er it y,
w it h an individual fact orial load of .92. The m or e sever e
t h e f a u l t i s , t h e h i g h e r t h e p r e v a l e n c e o f t h e
or g an i zat i on al an d p sy ch osoci al / eq u i p m en t f act or s
t hat pr oduced it .
By apply ing t he PCA pr ocedur e, t he num ber
o f v a r i a b l e s w a s r e d u ce d f r o m se v e n t o t h r e e
-psy ch osocial an d equ ipm en t aspect s, or gan izat ion al
aspect s and sever it y. Then, t he obt ained dat a ( m eans
of m edian values) w er e subm it t ed t o MDS. We used
t o sim plest MDS m odel t o obt ain j ust a classical m at rix
of t h e pr ogr am , t h e dissim ilar it y m at r ix . Dat a w er e
sym m et rical and t he t w o- dim ensional Euclidian m odel
could be used.
Th e p r o g r a m p r o d u ce s t h e h i st o r y o f t h e
i n t er act i on . As t h e m i n i m al s- st r ess i s l ow er t h an
0 . 0 0 1 , S PS S r e a c h e d t h i s v a l u e i n o n l y f o u r
i n t e r a c t i o n s . Th e s - s t r e s s m e a s u r e s t h e b e s t
ar r an gem en t , r an gin g fr om 1 ( w or st gr ou pin g) t o 0
( b est g r ou p in g ) . Th e p r og r am g en er at ed t w o ot h er
adapt at ion m easu r es, t h e “ Kr u sk al st r ess” m easu r e
( 0. 04492) and t he squar ed cor r elat ion coefficient ( r
-s q u a r e d = 0 . 9 9 2 6 2 ) b e t w e e n t h e d a t a a n d t h e
dist an ces. All t h r ee ar r an gem en t m easu r es in dicat e
t hat t he bidim ensional Euclidian m odel descr ibes t he
m ist ak es p er f ect ly.
I n t he AGI TATI ON ( AGT = - 4.512 and 0.4134) ,
RETENTI ON ( RET = 4.515 and 0.4133) and SELO (
-4.504 and 0.4141) , t he m edian values of t he exper t s’
sco r es f o r t h e sev en v a r i a b l es i n d i ca t ed t h a t t h e
o r g a n i z a t i o n a l a n d h u m a n f a c t o r s , a s w e l l a s
in for m at ion , t ot ally det er m in ed t h e m ist ak es. Gr ou p
-3 -2 -1 0 1 2 3
-1,0 -0,0 -1,0 -2,0
-2,0
Psychosocial and equipment aspect
s
Organizational aspects
Euclidian distances between nursing mistakes created by MDS
Sensory-motor level Procedure level Abstraction level Supervisioncontrol level
comt tro panc
traf
peca
suc
agt-corte dreno-over
ret-selo
quem rotu nutri
bloq
larin secr
soli
omi extu
oxim choq
trans pda
Figur e 1 - Repr esent at ion of dist ances bet w een nur sing
m ist ak es and t heir com plex it y lev els
Fig u r e 1 p r esen t s t h e MDS m ap , b ased on
t h e m a t r i x d a t a t h a t co r r esp o n d t o t h e d i st a n ces
bet w een t he 25 fault r epor t s, in t er m s of t he sev en
v ar iables under analy sis, w hich w er e gr ouped in t he
t hr ee fact or s. I t gr aphically pr esent s t he sim ilar it ies
an d / or d issim ilar it ies am on g t h em , r ef er r in g t o t h e
t h r e e c o m p o n e n t s i n d i c a t e d b y t h e PCA . We
pr ocedur e, abst r act ion and super v ision cont r ol lev el) ,
w h i c h a r e s i m i l a r i n t h e d i m e n s i o n s w e f o u n d
( psychosocial, equipm ent and or ganizat ional aspect s) .
Table 2 - Represent at ion of non- cont em plat ed nursing
i n t er v en t i o n s t h a t d et er m i n ed m i st a k es a n d t h ei r
corresponding socio- t echnical- st ruct ured syst em areas
Th e PCA sh ow ed t h e p r ev alen ce of h u m an
a n d so ci a l a sp e ct s o v e r e q u i p m e n t - r e l a t e d f a u l t
c a u s e s . We d e t e c t e d t h a t t h e i n v o l v e m e n t o f
or gan izat ion al, psy ch osocial an d equ ipm en t aspect s
decr eases t h e f or eseeabilit y of m ist ak es, leadin g t o
m o r e se v e r e co n se q u e n ce s f o r p a t i e n t s i n m o st
ca se s.
We a p p l i e d M D S t o o b t a i n a m a p t h a t
g r a p h i c a l l y p r e s e n t e d t h e s i m i l a r i t i e s a n d / o r
d i ssi m i l a r i t i e s b e t w e e n t h e f o u r i n t e r p r e t e d f a u l t
gr oups. Se n sor y - m ot or m ist a k e s ar e char act er ized
by t he det ect ion of pr oblem s, dat a pr ocessing, t hr ough
t he senses and t he cont r ol of m ot or act ions t o solv e
t hem . This lev el is based on sk ills and is r elat ed t o
t he ex ecut ion of highly r out ine act iv it ies in t he w or k
e n v i r o n m e n t , w i t h t h e o ccu r r e n ce o f l a p se s a n d
involving pr edom inant ly int r insic ( psychosocial) syst em
a s p e c t s . We f o u n d t h e f o l l o w i n g s e n s o r y - m o t o r
m i st a k e s: co m m e n t , e x ch a n g e , h i t , t r a n sf i x a n d
piece( 10).
I n all r epor t s, t h e act ion s t h at sh ou ld h av e
b e e n c a r r i e d o u t d i d n o t h a p p e n - n o t m a k i n g
inconvenient com m ent s t o colleagues w hile deliver ing
c a r e ; l a c k o f a t t e n t i o n i n l a b e l i n g a n d p u t t i n g
an at om ical p ieces in t h e ap p r op r iat e p lace t o sen d
t h em o n t o t h e l ab ; p u t t i n g t h e p at i en t i n a saf e
locat ion, and car e w it h dr ainages and infusions w hile
t r anspor t ing pat ient s fr om t he oper at ing r oom t o t he
PAR, pr ev ent ing cat het er t r ansfix at ion and obser v ing
w h e t h e r ca t h e t e r s a n d d r a i n s a r e cl o se d . I n t h e
r ep or t s, n u r sin g t eam m em b er s’ lack of p er cep t ion
a n d co n t i n u o u s o b se r v a t i o n o f p a t i e n t s a n d t h e
en v ir on m en t w er e ob ser v ed .
P r o c e d u r e l e v e l s r e f e r t o a n s w e r s t o
pr oblem s r elat ed t o pr e- est ablished r ules, t o ser v ice
r out ines. I t is t he r ule- based lev el. All m ist ak es ar e
r elat ed t o t h e def icien t st an dar dizat ion of t ech n ical
r out ines and lack of exper ience, r evealing t he degr ee
of aut om at ion in t ask act ions. The m ist ak es r efer r ed
t o t he lack of t est ing and per iodical m aint enance of
d e v i ce s l i k e t h e se cr e t i o n a sp i r a t o r ; l e a v i n g t h e
pat ient alone w hile st ill under t he effect of anest hesia;
put t ing t he pat ient in an insecur e place; not observing
t h e p at ien t ’s clin ical con d it ion s; n ot k n ow in g ab ou t
dr u gs t h at in t er act ; lack of k n ow ledge abou t dr ain s
an d i n f u si o n s an d h o w t o t ak e car e o f t h em ; n o t
k now ing how t o act in hem ody nam ic inst abilit ies and
anest het ic em er gencies. These m ist ak es w er e called:
suct ion, agit at ion, cut , overdose, ret ent ion, seal, burn,
label, feeding and block( 10). m
e t s y
S Nursingmistakes Creatingnursinginterventions l a c i g o l o n h c e T ) s t r o p e r 5 1 ( , k c o h S , n o i t e r c e S , n i a r D , g n i d e e F , l e b a L , l a e S , n o i t a t i g A , n o i t n e t e R , n o i t c u S , n r u B , e s o d r e v O , k c o l B , e g n a h c x E , x i f s n a r T e c e i P e r a C , n o i t a c i f i t n e d i k s i R , e m u l o v : k c o h s n i t n e m e g a n a m : n o i t a r t s i n i m d a n o i t a c i d e M y t e f a S , e r a c e b u T , l a r e t n e r a p , n o i t n e v e r p ll a F , n o i t a c i f i s n e t n i , n o i t a r t s i n i m d a l a t n e m n o r i v n E , t n e m e g a n a m y g o l o n h c e T , y t e f a S , t r o p p u s l a n o i t o m E , g n u l : e r a c e b u T , n o i t a u t i s y c n e g r e m e n i e r a C , e s o d r e v o : r o f y p a r e h t n o i t a c i d e M l a c i p o T , g n i r o t i n o m n o i t i d n o c n i k S n o i t a l u c r i c : e r a c l a c i g r u S , t n e m t a e r t l a i c o S ) s t r o p e r 5 ( , t s e r r A , t n e m m o C , e d u t il o S , e t a b u t x E n o i s s i m O , n o i t a c i f i s n e t n i y t e f a S , n o i t a r t s i n i m d a l a t n e m n o r i v n E n i e r a C , n o i t a t i c s u s e R , y t e f a S k s i R , n o i t a u t i s y c n e g r e m e n o i t n e v e r p ll a F , n o i t a c i f i t n e d i l a r u t c u r t S ) s t r o p e r 5 ( , r e t e m i x O , t u C , t i H x n y r a L , r e f s n a r T ll a F , t n e m e g a n a m y g o l o n h c e T l a t n e m n o r i v n E , n o i t n e v e r p y t e f a S , y t e f a S , n o i t a r t s i n i m d a g n i n o i t i s o P , n o i t a c i f i t n e d i
When t he m ist ak es occur r ed, w e consider ed
t h at t h e n u r sin g act ion s w er e n ot r ealized as t h ey
sh o u l d h av e b e e n . Ta b l e 2 p r e se n t s t h e n u r si n g
i n t e r v e n t i o n s( 1 3 ) t h a t w e r e n o t i m p l e m e n t e d o r
im plem ent ed inadequat ely, accor ding t o t he sur gical
cen t er ar eas t h e m i st ak es r ef er t o ( t ech n o l o g i cal ,
s o c i a l o r s t r u c t u r a l ) . Th e i n t e r v e n t i o n s a r e
in t er m ediar y cau ses in t h e occu r r en ce of m ist ak es,
det er m in ed by t h e in adequ acy of t h e ph y sical ar ea,
lack of definit ion of t eam m em ber roles, deficient st aff
t r a i n i n g , a sy st e m a t i c o b se r v a t i o n a n d e q u i p m e n t
in ad eq u acy.
DI SCUSSI ON
Th e an aly sis of m edian v alu es sh ow ed t h at
t he hum an fact or w as consider ed det er m inant for t he
lar ge m aj or it y of t h e r epor t ed m ist ak es. Pr ev en t ion
m easur es could hav e been est ablished, as t hey w er e
consider ed for eseeable. Mor eov er, t he hum an fact or,
lack of in f or m at ion an d , t o a lesser ex t en t , g r ou p
r el a t i o n s w er e co n si d er ed a s d et er m i n a n t f o r t h e
m ist ak es, m ost of w h ich d isp lay ed a r elat iv ely low
s e v e r i t y l e v e l . We o b s e r v e d t h e p r e v a l e n c e o f
or g an izat ion al cau ses ov er t h e m ist ak es’ d eg r ee of
foreseeabilit y, i.e. t he m ore organizat ional t heir causes
Ab st r a ct io n m ist a k e s r ef er t o t h e an sw er
due t o abst r act ion pr oblem s in t he handling of concept s
and logical pr oposals. I t is t he know ledge- based level.
Th e s e i n v o l v e p e r c e p t i o n , o b s e r v a t i o n a n d
sur veillance er r or s r elat ed t o t he pat ient ’s cont inuous
obser v at ion , r em ain in g by h is side, per ceiv in g sign s
an d sy m pt om s of abn or m alit ies, pay in g at t en t ion t o
t h e p at i en t ’ s cl i n i cal r esp o n ses t o t h e an est h et i
c-su r g i cal act an d c-su r v ei l l an ce. Th e m i st ak es cal l ed
ex t u b at e, ar r est , sh ock an d t r an sf er( 1 0 ) r ef er r ed t o
accident al ex t ubat ion and r isk of falls dur ing pat ient
t r an sp or t ; t h e em p loy ee’s t ot al lack of k n ow led g e
a b o u t r e s u s c i t a t i o n m a n e u v e r s i n c a s e s o f
cardiorespirat ory arrest and about clinical observat ion
w i t h a v i e w t o t h e e a r l y d e t e c t i o n o f s i g n s o f
h y p o v o l e m i c s h o c k ; d a m a g e d a n d i n s u f f i c i e n t
ox i m et er s.
Su p e r v isio n co n t r o l m ist a k e s m ain t ain a
close cor r elat ion am on g t h e ear lier lev els ( sen sor y
-m ot or, p r oced u r e an d ab st r act ion ) ; t h e in t er act ion
bet w een nur sing t eam m em ber s, anest het ist , sur geon
and pat ient r equir es const ant at t ent ion, obser v at ion,
p e r c e p t i o n a n d s u r v e i l l a n c e t o d e t e c t d i f f e r e n t
problem s and act ions required for t heir solut ion. I t is
a lev el b ased on r u les, sk il ls an d k n ow l ed g e. Th e
lapses, m ist ak es an d er r or s t h at occu r at t h is lev el
culm inat ed in v er y sev er e er r or s, w hose psy chosocial
and or ganizat ional aspect s ar e im por t ant in pr oducing
t he errors. We found t he follow ing supervision cont rol
m ist ak es: lar y nx , secr et ion, solit ude and om ission( 10),
referring t o sit uat ions in w hich t he pat ient had a glot t is
edem a and t her e w as no lar y ngoscope in t he r oom ;
p r esen t ed n on - asp ir ed secr et ion at t h e ap p r op r iat e
m om ent ; pr esent ed car dior espir at or y ar r est because
he w as alone, besides a case in w hich t he doct or w as
called and did not r espond.
We con sider t h at essen t ial f act or s f or er r or
analysis and r elat ed t o t he envir onm ent , t he t ask and
t he individual( 14). From t he per spect ive of t he sur gical
cen t er as a socio- t ech n ical- st r u ct u r ed sy st em( 7 ), w e
b el i ev e t h at i n d i v i d u al asp ect s i n cl u d e t h e h u m an
f a c t o r ( k n o w l e d g e , a s p i r a t i o n s , e x p e c t a t i o n ,
m ot ivat ions, opinions and values) and gr oup r elat ions
( social in t er act ion s) , w h ich cor r espon d t o t h e social
sy st em . The t ask is r elat ed t o equipm ent , m at er ials,
t echniques, physical area and act ivit ies, corresponding
t o t h e t ech n olog ical sy st em . En v ir on m en t al f act or s
include t he inst it ut ion’s philosophy in t erm s of it s goals
a n d v a l u e s , i n v o l v i n g t h e o r g a n i z a t i o n a l f a c t o r
( o r g a n i z a t i o n , f l o w c h a r t , f u n c t i o n a n d s e r v i c e
d e s c r i p t i o n s , s t a n d a r d s , r u l e s , r e g u l a t i o n s a n d
r e g i m e n t s ) a n d i n f o r m a t i o n , w h i c h r e f e r t o t h e
st r u ct u r al sy st em .
I n v iew of t his concept ion, w e consider t hat
“ a c c i d e n t s g e n e r a l l y r e s u l t f r o m i n a d e q u a t e
int er act ions bet w een m an, t ask and env ir onm ent ”( 15),
and t hat m ist akes r efer t o deviat ions t hat det er m ined
low syst em reliabilit y. Reliabilit y is “ t he probabilit y t hat
a syst em w ill execut e funct ions w it hout m ist akes w it hin
a giv en t im e int er v al”( 15).
Th e m ist ak es w e f ou n d can be classif ied in
t e r m s o f o r g a n i za t i o n a l , p sy ch o so ci a l / e q u i p m e n t
an d sev er it y asp ect s, an d w e ar r iv ed at f ou r b asic
l e v e l s a t w h i c h t h e y o c c u r : s e n s o r y - m o t o r,
p r o c e d u r e , a b s t r a c t i o n a n d s u p e r v i s i o n c o n t r o l .
Th ese lev els ar e con n ect ed w it h t h e h u m an cogn it iv e
act iv it ies of sk ill, r u le an d k n ow led g e, t o d if f er en t
ex t en t s an d in v olv in g m ist ak es der iv in g f r om lapses,
m i st ak es an d er r or s.
CONCLUSI ONS
We consider t hat t he t heor y of hum an er r or
can en r ich t h e an aly sis an d p r ev en t ion of n u r sin g
m i s t a k e s a n d c o n c l u d e t h a t t h e h u m a n f a c t o r
per m eat es all m ist ak es, w hich w er e m ost ly pr oduced
by m ist ak es an d lapses in t h e t ask plan n in g ph ase.
The lack of sk ill and at t ent ion play ed a det er m inant
r o l e i n m i st a k e s d u r i n g n u r si n g ca r e d e l i v e r y t o
pat ient s in PAR.
Mist ak es ar e b asically d u e t o p sy ch osocial
and or ganizat ional aspect s and consist in lapses and
m ist akes at sensor y- m ot or and pr ocedur e level, w hich
o ccu r r e d d u r i n g t a sk p l a n n i n g ; a n d i n e r r o r s a t
ab st r act ion an d su p er v ision con t r ol lev el, occu r r ed
dur ing t ask pr epar at ion and execut ion. The equipm ent
f a ct o r d o es n o t d et er m i n e t h e m i st a k es a n d , t h e
g r e a t e r t h e se v e r i t y o f t h e f a u l t , t h e h i g h e r t h e
p r ev al en ce o f t h e o r g an i zat i o n al an d p sy ch o so ci al
aspect s t hat pr oduced it .
Sen sor y - m ot or an d pr ocedu r e m ist ak es ar e
light and m oder at e, w hile abst r act ion and super vision
con t r ol m ist ak es ar e eit h er sev er e or v er y sev er e.
We ident ified five basic causes during nursing care t o
p at ien t s in PAR - p h y sical in ad eq u acy, lack of r ole
definit ion, deficient t r aining, asy st em at ic obser v at ion
and equipm ent inadequacy, all of w hich w ere connect ed
w i t h p sy ch o so ci al an d o r g an i zat i o n al asp ect s t h at
Th e m ist ak es ar e based on t h e beh av ior of
t h e e n t i r e m a n - t a sk- e n v i r o n m e n t sy st e m . I n t h i s
con t ex t , m ist ak es ar e cau sed b y sy st em ob j ect iv es
t h at ar e n ot com plied w it h . Th e im pr ov ed r eliabilit y
of t he sur gical cent er sy st em , especially of t he PAR
care t ask, is illust rat ed by essent ial reparat ions, such
as t r ai n i n g an d r ecy cl i n g , r o l e d ef i n i t i o n , p h y si cal
r est r uct ur ing, qualit at iv e and quant it at iv e equipm ent
adapt at ion, besides t he im plant at ion of nur sing car e
sy st e m i z a t i o n f o r ca r e d e l i v e r y t o p e r i o p e r a t i v e
su r g i cal p at i en t s, i n w h i ch seq u en ces o f act i v i t i es
d ef in ed b y a n u r se ar e d elib er at ely car r ied ou t t o
guar ant ee t hat pat ient s r eceive t he best possible car e.
ACKNOW LEDGEMENTS
O u r s i n c e r e s t t h a n k s t o Pr o f . D r. Pa u l
St ephaneck, Ret ired Full Professor from t he Universit y
of São Paulo at Ribeir ão Pr et o Facult y of Philosophy
for serving as t he advisor t o our Doct oral Dissert at ion,
w hich gave rise t o t he result s present ed in t his art icle.
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