Condiciones productoras del error en el trabajo de enfermería

Investigación documental, exploratoria, cuantitativa-cualitativa. Se recogieron las informaciones de 13 procesos ético-disciplinarios del COREn (Consejo Regional de Enfermería) de Bahía, durante el período comprendido entre 1995 y 2010, que tenían como objetivo denunciar errores cometidos por trabajadoras de enfermería. Los datos cuantitativos se analizaron mediante estadística descriptiva y en el análisis de los datos cualitativos se utilizó el abordaje de la Teoría del Error Humano y de la Sociología del Trabajo.

Resultados:

Las técnicas y auxiliares de enfermería son las trabajadoras más denunciadas. La principal denunciante fue la organización de la salud, a través de la coordinación del servicio de enfermería y el turno con más incidentes, el diurno.

Consideraciones finales:

Los errores cometidos por las trabajadoras de enfermería demuestran que las condiciones productoras de dichos errores están presentes en el contexto de todos los procesos, siendo el sub-dimensionamiento y la intensidad del trabajo, las circunstancias más recurrentes.

Descriptores:
Enfermería; Condiciones de Trabajo; Trabajo; Error Médico; Seguridad del Paciente

Characteristics of the workers		n
Professional category
Nurse		04
Nursing technician		03
Nursing assistant		11
Total		18
Gender
Male		0
Female		18
Total		18
Age group
20-30		4
31-40		10
41 and older		3
Total		18

Object of complaint		n
Incorrect medication		2
Incorrect patient		3
Incorrect action		2
Incorrect route		5
Incorrect dosage		1
Total		13

Error	Error-producing conditions	Evidence on the processes
Incorrect route	Understaffing of workers and intensity of work	I was on duty and took over the four clinics and the CME, so I had around one hundred and fifty patients. (Process 4)I got confused at the time because I was administering medication on many patients and working alone. (Process 4)
	Lack of supervision of the work process of nursing technicians and assistants	There is no direct and constant supervision over the nursing assistant in the outpatient clinic, because there is no professional available for this. There are 02 [two] nurses, 01 [one] in charge of the nursing consultation and the other in charge of drug manipulation. (Process 7)
	Intensity of work	Did anyone ask if I was okay to work that night? I decided to stay so that my night colleague wouldn’t work alone. (Process 1)
	Labor rights issues	[...] but she was overloaded because she was from Fapex [outsourced by the Research and Extension Support Foundation of the Federal University of Bahia] and had no right to family support [...]. (Process 3)
Incorrect patient	Lack of material and equipment	[...] there is lack of materials, the equipment is not new, there is no protocol, we do not have an emergency car, even though we requested one several times. (Process 2)
	Intensity of work	A hectic day, full of occurrences, tired mothers worried about their children, many attributions as you already know [...]. (Process 10)
	Understaffing of workers and intensity of work	How many patients were scaled for each professional? There are about thirteen for each nursing technician, I believe that on average there are 42 or 45 beds. Many patients are severe because the hospital serves the entire southwest region. They often have ICU indication, but there is no bed available so they stay in the medical clinic waiting for the vacancy. (Process 11)
Incorrect medication	Understaffing of workers and intensity of work	We questioned the presence of only 02 nursing assistants to assist 13 patients, plus the delivery room, the prompt care and inter-occurrences in the unit. (Process 12)
	Inadequate medication storage	In the refrigerator where you keep the medications are there specific compartments for anesthetics? No, it’s a small refrigerator and the medications are in the refrigerator door and on the shelves, including blood without separation. (Process 5)
	Labor rights issues	Are you entitled to rest during the shift? No. When the shift is calmer, which was not the case, we take the mattresses from the cradle and put them on the floor and we take turns to rest. (Process 12)
	Intensity of work	We, nursing assistants, must leave our shift with all patients bathed, beddings changed, vital signs checked, medications delivered, dressings done, as well as leave all the material used already washed, dried and packed for sterilization. (Process 5)
Incorrect action	Understaffing of workers and intensity of work	And since there are no nurse in the institution in some periods, some procedures that are exclusive to the nurse are performed by the nursing assistants and technicians. Also, some activities are aggregated when some sectors such as laundry and pharmacy are not functioning. (Process 6)A busy night shift, at that time I was responsible for pediatric patients and the outpatient clinic from 7 p.m. to 10 p.m., and then I left the clinic to the next colleague, and continued in pediatrics (Process 8)
Incorrect dosage	Understaffing of workers and intensity of work	How many nurses work there? Only one nurse worked in two emergency units. The emergency has a turnover of about 700 patients per day [...]. (Process 13) Usually the shift in the hospital is quite busy. (Process 13)
Incorrect dosage	Lack of material and equipment	Do you think the hospital has the structure to follow up the oncology patient coming from other institutions? No, there is a lack of physical structure, lack of training and lack of equipment for personal protection. (Process 13)

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] CORRESPONDING AUTHOR: Handerson Silva Santos. E-mail: handerson_bahia@yahoo.com.br