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工作流程:理解护理差错的基础。

Work process: a basis for understanding nursing errors.

作者信息

Forte Elaine Cristina Novatzki, Pires Denise Elvira Pires de, Martins Maria Manuela Ferreira Pereira da Silva, Padilha Maria Itayra Coelho de Souza, Ghizoni Schneider Dulcinéia, Trindade Letícia de Lima

机构信息

Universidade Federal de Santa Catarina, Departamento de Enfermagem, Florianópolis, SC, Brasil.

Universidade Federal de Santa Catarina, Programa de Pós-graduação em Enfermagem, Florianópolis, SC, Brasil.

出版信息

Rev Esc Enferm USP. 2019 Aug 19;53:e03489. doi: 10.1590/S1980-220X2018001803489.

Abstract

OBJECTIVE

To identify work process-related causes associated with nursing errors reported in newspapers.

METHOD

This was a documentary and qualitative study based on the work process theory and hermeneutic analysis that examined 112 news articles published between 2012 and 2016 in 21 high-circulation Brazilian newspapers, organized and codified using Atlas.ti software.

RESULTS

The causes associated with the reported errors were associated with workforce (lack of professionals and training, turnover, work overload, lack of information, recklessness, negligence, and distraction); work instruments (similar labels or packages, storage, lack of product identification and information, and medical prescriptions); and the object of nursing work (overcrowding and specific characteristics of patient).

CONCLUSION

Analysis of the possible causes of reported errors identified the negative outcomes of nursing work, while also identifying elements of the work process that influenced these results. The findings emphasize the importance of understanding these errors so they can be avoided and of reviewing nursing work conditions to guarantee quality and safety of care.

摘要

目的

确定与报纸报道的护理差错相关的工作流程相关原因。

方法

这是一项基于工作流程理论和诠释分析的文献与定性研究,研究了2012年至2016年间在巴西21家发行量较大的报纸上发表的112篇新闻文章,使用Atlas.ti软件进行组织和编码。

结果

与所报道差错相关的原因与劳动力(专业人员和培训不足、人员流动、工作负荷过重、信息缺乏、鲁莽、疏忽和分心)、工作工具(相似的标签或包装、储存、产品标识和信息缺乏以及医疗处方)以及护理工作对象(过度拥挤和患者的特殊特征)有关。

结论

对所报道差错的可能原因进行分析,确定了护理工作的负面结果,同时也确定了影响这些结果的工作流程要素。研究结果强调了理解这些差错以避免差错以及审查护理工作条件以确保护理质量和安全的重要性。

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