Journal of Nursing

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, 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, 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, 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, 2006).


It is worthy to mention that the number of errors reported at each hospital represents only the tip of the iceberg (Hackel, 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, 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, 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, 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, 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, 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, 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, 2003). Bar-Code Medication Administration Systems have been shown to be effective in managing medication errors (Cochran, 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. 


Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights


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Editor-in Chief:
Kirsten Nicole

Editorial Staff:
Kirsten Nicole
Stan Kenyon
Robyn Bowman
Kimberly McNabb
Lisa Gordon
Stephanie Robinson

Kirsten Nicole
Stan Kenyon
Liz Di Bernardo
Cris Lobato
Elisa Howard
Susan Cramer