title: Nursing faults in the recovery period of surgical patients.
abstract: This is a descriptive study based on the theory of human error, in order to analyze and classify nursing errors during the nursing care of surgical patients at recovery. Twenty-five (25) fault reports were collected through a semi-structured interview. Those reports were submitted to 15 nurse experts to evaluate the risk of seriousness; human, equipment and organizational factors involved; members interaction; information and reversibility of the accident. Faults were directly attributed to psychosocial and organizational aspects, equipment and seriousness. A multidimensional scaling test (MDS) was applied and a graph was obtained. It showed four groups of faults, due to problems related to sensory-motor, procedure, abstraction and supervision control. In conclusion, the faults were caused by non-defined personnel roles, continuing education deficiency, non-systematic observation, inadequate space and equipment.
authors.affiliation: College of Nursing, Minas Gerais Federal University. tchianca@enf.ufmg.br
authors.forename: Tânia Couto Machado
authors.initials: TC
authors.lastname: Chianca
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000145:classification / Q000706:statistics & numerical data*; D016528:Postanesthesia Nursing / Q000592:standards*; D011182:Postoperative Care / Q000451:nursing*