Role of Registered Nurses in Error Prevention, Discovery and Correction
Patient safety and satisfaction are the two essential components of nurse care. Edward Wilson filed a lawsuit against the Beverly Health Care center, West Virginia that was responsible for his wife Carol's death in Jan 2004. He alleged that she died from acute Pneumonia due to multiple bacterial infections she had developed due to poor infection control methods during assisted breathing and the ICU nurse had ignored the routine safety checks to be done during assisted breathing. Thus, any error in patient safety checks, interventions or poor infection control methods often results in patient's death or disability. Such error events are termed Adverse Medical Events. Further, such Adverse Medical Events lead a nurse into serious medical litigations under the "Medical Malpractice Law". Medical Malpractice Law in USA is part of tort or personal injury law. Nursing practice is liable for six kinds of authority, viz, The federal or central law, The law of the state, The International Code, Institutional Rules and Regulations, Standing Orders of Chief and Precedent Court Decisions (Zwemer, 1995). The Medical Guidelines and laws in USA help manage medical errors better. As per USA jurisprudence system, the Standard of Nurse Care is different from the Quality of Care (Simon, 2004). The Standard of Care is a legal concept, normatively defined, that is applied to the specific fact pattern of a case in litigation (Simon, 2004). The definition of Standard of Care differs between states in USA. Quality of care is defined as the adequacy of total care the patient receives from health care professionals, including third-party payers (Simon, 2004).
Nurses in Error Prevention
Since nurses are intimately involved in the health care delivery and are ultimately responsible in acute phases of the disease, it is important for nurses to understand the factors contributing to errors for effective prevention. Improving safety at the point of care is the most important aspect of error prevention. Incorrect drug calculations, lack of individual knowledge and failure to follow established protocol, time pressures, fatigue, understaffing, inexperience, design deficiencies and inadequate equipments create opportunities for error (Carlton and Blegen, 2006). The medication errors that cause harm include errors related to infusion of high-risk medications and an intravenous medication safety system has been designed recently to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. The new safety system has been shown successful in averting 99 potential infusion errors in 8 months (Hatcher et.al, 2004). Failure mode and effect analysis (FMEA) is a recent technique to prevent chemotherapy errors. It is a proactive process in which nurses play a vital role and is based on systematic thinking about the safety of patient care (Leos et.al, 2006).
A randomized controlled trial to study the impact of having dedicated medication nurses on the medication administration error rate has shown that medication errors are usually related to systems design issues and management rather than just nurses (Greengold et.al, 2003). A quantitative study to explore the influence of working conditions on the occurrence of medical near-miss errors related to intravenous medication has shown that nurse workload and lack of experience lead to errors (Seki and Yamazaki, 2006). A study to investigate the strategies used by nurses to recover medical errors in an emergency department setting has revealed five themes to describe the methods used by nurses to identify errors in the ED setting, namely, surveillance, anticipation, double checking, awareness of the "big picture," and experiential "knowing." The study has also revealed five themes to describe the methods used by the nurses to interrupt errors, namely, patient advocacy, offer of assistance, clarification, verbal interruption, and creation of delay. The study has identified assembling the team and involving leadership as themes to describe error correction by nurses (Henneman et.al, 2006).
It is worthy to mention that the number of errors reported at each hospital represents only the tip of the iceberg (Hackel et.al, 2006). Registered nurses have a vital role in discovering medical error. A study to describe the type and frequency of errors detected by American nurses in a sample of 502 nurses during a 28-day period has shown that the errors being discovered by nurses include medications, procedural errors, charting and transcription errors (Rogers et.al, 2008). A Research study has shown that these errors often result from a combination of factors that lead to the breakdown of workflow and also classified errors associated with misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and switching of one patient's identification information with those of another (Hakimzada et.al, 2008). In spite of strict clinical measures there are certain areas like blood transfusion process where administrative errors lead to fatal acute haemolytic reactions. Nurses being responsible for the final bedside check before transfusion, have the final opportunity to discover such mis-transfusions (Mole et.al, 2007).
Today, there is a departure from traditional approach to error correction by the Extensive Use of Technology, practice innovations likes Documentation Based Practice and Evidence Based Practice. It is necessary to develop an effective error reporting system and to understand the barriers and facilitators for the design of a medical error reporting system to effectively correct errors (Karsh et.al, 2006). Spontaneous reporting is the main tool in most countries today. The use of Electronic Reporting Systems and systemically evaluating the medical errors and adverse events reported are essential for correcting systemic errors and improving patient safety (Kima, , and et.al, 2006). There are no practical advices or guidelines for nurses and for emergency nurses in particular, regarding the issue of medical error recognition, reporting, and correction (Hohenhaus, 2008). Most of the Registered Nurses have been shown to have apprehensions that such reported information about errors would be used against them under the current medical malpractice system taking us to the firm conclusion that there is a need to re-design the entire malpractice system with its components of punitive litigations and compensations placing the Adverse Medical Events as an exclusive event with reference to the field of medicine/nursing, where, patient care is the main element and not patient harm. A national, provincial or territorial quality care council dedicated solely for the purpose of correcting such errors can effectively correct such errors (Kalra, 2004).
A Web-based ICU Safety Reporting System (ICUSRS) has been developed recently to identify high-risk situations and working conditions in an ICU, to help change systems, and to reduce the risk for error (Wu et.al, 2002). Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that has been formed to collect and analyse confidential data on primary care medical errors and develop interventions to correct and reduce such errors (Pace et.al, 2003). Bar-Code Medication Administration Systems have been shown to be effective in managing medication errors (Cochran et.al, 2007). Near-miss events are a valuable source of data because they occur more frequently than, but share many characteristics and causes of, actual events. The Medical Event Reporting System for Transfusion Medicine (MERS-TM) is a system that collects, classifies, and analyzes events including data on near misses as well as actual events (Kaplan et.ala, b, c, , 2002).
Nurses can take a more prospective, risk-reduction approach to medical errors (Wolf, 1989). Adoption of appropriate technology blended with a confidential error reporting system that protects the professional interests of nurses will be effective in reducing, preventing and correcting medical errors. There is an urgent need to identify factors that will further help nurses in error identification, prevention and correction.
- A. Forogh Hakimzadaa, Robert A. Greenb, Osman R. Sayanb, Jiajie Zhangc and Vimla L. Patel (2008). The Nature and Occurrence of Registration Errors in the Emergency Department. International Journal of Medical Informatics.77(3); 169-175.
- Albert W. Wu, Peter Pronovost and Laura Morlock (2002). ICU Incident Reporting Systems. Journal of Critical Care. 17(2); 86-94.
- Ben-Tzion Karsha, , , Kamisha Hamilton Escotob, , John W. Beasley and Richard J. Holden (2008). Toward A Theoretical Approach To Medical Error Reporting System Research And Design. Applied Ergonomics 37(3); 283-295.
- Carlton and Blegen (2006). Medication-Related Errors: A Literature Review of Incidence and Antecedents. Annu Rev Nurs Res. 24:19-38.
- Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW (2007). Errors Prevented By and Associated With Bar-Code Medication Administration Systems. Jt Comm J Qual Patient Saf. 33(5): 293-301, 245.
- Debra Dunn (2003). Incident Reports- Correcting Processes and Reducing Errors. AORN. 78(2); 211-233.b, a
- Elizabeth A. Hennemana, , , Fidela S.J. Blank,b, 1, Anna Gawlinski c, 2, and Philip L. Henneman (2006). Strategies Used By Nurses to Recover Medical Errors in an Academic Emergency Department Setting. Applied Nursing Research.19(2); 70-77.
- Greengold NL, Shane R, Schneider P, Flynn E, Elashoff J, Hoying CL, Barker K, Bolton LB (2003). The Impact of Dedicated Medication Nurses on the Medication Administration Error Rate: A Randomized Controlled Trial. Arch Intern Med. 27; 163(19):2359-67.
- Hackel R, Butt L, Banister G (1996). How Nurses Perceive Medication Errors? Nurs Manage.27(1):31, 33-34.
- Harold S. Kaplana, b, c, , Jeannie L. Calluma, b, c, Barbara Rabin Fastmana, b, c and Lisa L. Merkley (2002). The Medical Event Reporting System For Transfusion Medicine: Will It Help Get The Right Blood To The Right Patient? Transfusion Medicine Reviews 16(2); 86-102.
- Hatcher I, Sullivan M, Hutchinson J, Thurman S, Gaffney FA (2004). An Intravenous Medication Safety System: Preventing High-Risk Medication Errors At The Point Of Care. J Nurs Adm. 34(10): 437-439.
- Jawahar Kalra (2004). Medical Errors: Overcoming the Challenges. Clinical Biochemistry. 37(12); 1063-1071.
- Jeongeun Kim a, , and David W. Bates (2006). Results of a Survey on Medical Error Reporting Systems in Korean Hospitals. International Journal of Medical Informatics. 75(2); 148-155.
- Mole LJ, Hogg G and Benvie S (2007). Evaluation Of A Teaching Pack Designed For Nursing Students To Acquire The Essential Knowledge For Competent Practice In Blood Transfusion Administration. Nurse Educ Pract.7(4):228-37. Epub 2006 Oct 31.
- Rogers AE, Dean GE, Hwang WT and Scott LD (2008). Role of Registered Nurses in Error Prevention, Discovery and Correction. Qual Saf Health Care. 17(2); 117-121.b , ,
- Seki Y and Yamazaki Y (2006). Effects of Working Conditions on Intravenous Medication Errors in a Japanese Hospital. J Nurs Manag.14(2):128-139.
- Sheridan-Leos N, Schulmeister L, Hartranft S (2006). Failure Mode and Effect Analysis: A Technique to Prevent Chemotherapy Errors. Clin J Oncol Nurs. 10(3):393-398.
- Simon RI (2004). Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Arlington, VA: American Psychiatric Publishing, Inc.
- Susan McDaniel, Hohenhaus and aWellsboro Penn (2008). Emergency Nursing and Medical Error- A Survey of Two States. Journal of Emergency Nursing. 34(1); 20-25.
- Wilson D Pace , a, , Elizabeth W Staton,a Gregory S Higginsa, Deborah S Maina, David R Westa and Daniel M Harris (2003). Database Design to Ensure Anonymous Study of Medical Errors: A Report from the ASIPS Collaborative. Journal of the American Medical Informatics Association. 10(6); 531-540.
- Wolf ZR (1989). Medication Errors and Nursing Responsibility. Holist Nurs Pract. 4(1):8-17.
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Liz Di Bernardo