Budi Santoso Andreasta Meliala Fitri Haryanti(1*)

(*) Corresponding Author


Background: The complexity of care processes, patient’s
critical condition, high workload, and high level of psychological
stress among the nurses in the Intensive Care Unit (ICU) could
lead to potential nursing errors (NE). This research aims to
identi fy nursing errors, categories of pat ient harm,
nurses’profile, and the contributing factors perceived by the
nurse in the ICU of Dr. Oen Surakarta Hospital.
Methods: This was an observational study conducted using
observation method with TERCAP modification instrument to
identify any nursing practices in ICU to patients that were
admitted during one-month study period. In total, 115 patients
were observed and the analysis was conducted descriptively.
Results: We found 8 types of 15 NE events, i.e. self extubation
(26,66%), uprooted of IV line (20%) and NGT (13,33%), wrong
dose (13,33%), omission (6,67%), wrong reason (6,67%), repricking
in blood sugar examination (6,67%), and phlebitis due
to wrong route (6,67%). Eight events (53,33%) did not harm
the patients and the other 7 events (46,67%) harmed the
patients temporarily. The profile of nurses involved was mostly
with diploma education (93,33%), having special education/
training (80%), and more than 3 years working period in the
ICU (86,67%). Eight TERCAP categories were related to
medication errors (33,33%), documentation errors (26,67%),
lack of attentiveness (73,33%), inappropriate clinical judgment
(73,33%), lack of prevention (26,67%), lack of/inappropriate
intervention (13,33%), missed/mistaken interpretation
(33,33%), and lack of professional responsibility (40%). While
the highest perceived contributing factor was overloaded task
Conclusion: The common type of events was self-extubation.
No permanent harm was found. This study recommends
continuous dissemination on patient safety for nurses to
encourage reporting of NE events.
Keywords: intensive care, nursing errors, nursing practices


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