Nursing faults in the recovery period of surgical patients

Rev Lat Am Enfermagem. 2006 Nov-Dec;14(6):879-86. doi: 10.1590/s0104-11692006000600008.


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.

MeSH terms

  • Humans
  • Medical Errors / classification
  • Medical Errors / statistics & numerical data*
  • Postanesthesia Nursing / standards*
  • Postoperative Care / nursing*