Improving patient safety: how and why incidences occur in nursing care

The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU) in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

Eixos mobilizadores em química

Over the last five years there have been significant changes in higher education in Brazil as well as in research funding. As a contribution to the development of Science and Technology, and aiming to portray Chemistry today in Brazil, in the context of last year´s elections for President, State Governors, National Congress and Legislative Chamber, the Directors and Consulting Council of the Brazilian Chemical Society, SBQ, initiated in 2002 a series of activities to produce a document entitled Mobilizing Axes in Chemistry. This discusses undergraduate and graduate teaching in Chemistry, a new model for research funding, and the overall state of the art, and future perspectives. Six mobilizing axes have been identified and discussed to date: 1. Training of highly qualified personnel; 2. Decentralization, and discouragement of institutional in-breeding; 3. Stimulation of entrepreneurship and interdisciplinarity; 4. A guaranteed budget for Science and Technology; 5. Proactive interaction of academics with economic activity; and 6. Removal of institutional bottle-necks of all sorts. The Brazilian Chemical Society hopes that the new administration will in the near future begin the task of improving the national education system and increase funding for Science and Technology.