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Role of registered nurses in error prevention,discovery and correction A E Rogers,1 G E Dean,2 W-T Hwang,3 L D Scott4 nurses play in discovering and correcting errors Background: Registered nurses have a vital role in discovering and correcting medical error.
The surveillance role of nurses is particularly University of New York atBuffalo, Buffalo, New York, USA; Objective: To describe the type and frequency of errors important in the intensive care environment since detected by American critical care nurses, and to the rate of preventable adverse drug events and ascertain who made the errors discovered by study potential adverse drug events in ICU settings is nearly twice the rate in non-ICU settings.7 Not only are ICU patients exposed to more medications Methods: Daily logbooks were used to collect informa-tion about errors discovered by a random sample of 502 and treatments than patients in general care areas, critical care nurses during a 28-day period.
they are critically ill, with little natural resilience or Results: Although the majority of errors discovered and ability to defend themselves from the conse- quences of human error. Thus the potential for corrected by critical care nurses involved medications (163/367), procedural errors were common (n = 115).
patient harm is greater. In fact, approximately 29% Charting and transcription errors were less frequently of the errors observed in an ICU (Israel) were discovered. The errors discovered by participants were categorised as potentially harmful, causing signifi- attributed to a wide variety of staff members including cant deterioration in the patient’s status or death.8 nurses, doctors, pharmacists, technicians and unit Little is known about nurses’ discovery of errors that do not involve medications, or who makes the Conclusions: Given the importance of nurses in errors that are subsequently discovered by nurses.
maintaining patient safety, future studies should identify Therefore, the purpose of this study is to describe factors that enhance their effectiveness to prevent, the type and frequency of errors detected by intercept and correct healthcare errors.
critical care nurses, and to ascertain wheneverpossible who made the error discovered by theparticipants. It is hoped that this information will Traditional roles of nursing include surveillance, assist in future root cause analysis for error for example, watching patients for changes in their prevention among healthcare providers.
condition and protecting them from harm/errors.
Even as students, nurses are taught that it is their duty and obligation to question doctors’ orders and The data for this diary-based descriptive study to refuse to administer medications or carry out were collected as part of a large American study procedures that they feel are inappropriate.1 Despite their important role in maintaining safety, reported by hospital staff nurses and errors. Since most studies of patient safety have focused the methodology and sample have been described exclusively on the role of registered nurses in in detail elsewhere, they are described only briefly administering medications, and not on their role in error prevention, discovery or correction.2 Few studies have examined the part that nurses play in discovering and correcting inappropriate or A total of 502 American critical care nurses dangerous medication orders, transcription errors participated in this study. As expected, the sample and dispensing errors. When evaluating 334 med- was predominately female (92.8%), Caucasian ication errors, Leape and colleagues3 found that (86.7%), middle-aged (mean (SD) age 44.4 (8.0) half of the errors were caught before they reached years, range 23–66 years), and were experienced the patient, with 85% of these errors intercepted (mean years experience 18.4 (8.5) years). Almost all by registered nurses; the remaining 15% were participants worked 12-hour shifts (87.8%). All detected by pharmacists. In another study,4 regis- participants were registered nurses who worked tered nurses reported more adverse medical events full-time (at least 36 hours per week) as a staff than doctors in training (resident doctors and nurse in a critical care area (table 1).
pulmonary/critical care fellows), intensive careattending doctors and other members of the intensive care unit (ICU) staff such as pharmacists, Data were collected on a daily basis for 28 days unit secretaries, and students (59.1% vs 27.2%, using logbooks. Participants completed 15 items 2.6% and 4.7%, respectively). In addition, over 50% about their sleep and mood each day, and an of the critical incidents documented in a paediatric additional 17 items on days they worked. On ICU were discovered by registered nurses.5 Finally, workdays, nurses were asked about their scheduled several of the examples included in a paper by and actual work hours, their level of alertness, and Elfering and colleagues6 allude to the part registered whether or not they made any errors, or discovered Qual Saf Health Care 2008;17:117–121. doi:10.1136/qshc.2007.022699 because of insufficient information). Similar procedures were Employment settings of the registered nurses used to further subdivide medication administration errors intosix subcategories: wrong patient, wrong medication, wrong dosage, wrong route of administration, wrong time and omitted Next, all narratives were examined to determine who made the error (doctor, pharmacist, another nurse, unit clerk, technician). If participants did not identify who made the error or if it could not be determined who made the error, it was included in the unable to classify category. All errors were examined to determine if they were discovered prior to reaching the patient. Minimal discrepancies in coding were identified at each step and resolved with 100% agreement among the investigators. Finally, clustered x2 tests were performed to determine if the number of discovered errors were related to hospital size or type of critical care unit.
someone else’s error. Space was also provided for participants to describe any practice deviations (errors) that they may have There were 367 errors discovered by 184/502 participants during made or discovered during their work shift. Prior to beginning the 28-day data-gathering period. The number of errors the study, all items and the logbook format itself was pilot discovered by an individual nurse ranged from 0 to 12. Errors involving medication administration were the most frequently Although not often used to collect information about medical discovered by nurses (44.4%), followed by procedural errors error, there is some evidence that daily, anonymous, end-of- (31.3%). Charting and transcription errors were less frequently shift reporting of errors is a valid data collection approach.
discovered (15.0% and 2.7%, respectively). The most common Several studies have shown that nurses and resident doctors are medication error discovered by critical care nurses participating more likely to report medication errors, needle sticks, potential in this study was the administration of an incorrect dose of a injuries to patients and other adverse events using anonymous prescribed medication (45.1%). Discovering that the wrong drug end-of-shift reports than completing traditional incident had been administered or that a dose of a prescribed medication had been omitted was also relatively common. Examples ofdiscovered errors are presented in table 2.
Errors made by other registered nurses were the most frequently reported by participants (40.6%), followed by doctor A letter describing the study and a demographic questionnaire ordering errors (8.5%). There were 130 errors that could not be was sent to 5261 members of the American Association of attributed to a particular type of provider (see tables 3 and 4).
Critical Care Nurses. Of the 2184 nurses who returned the Only 43 of the 367 errors (11.7%) were discovered before they questionnaires, only 1148 met the criteria for participation—for reached the patient. Many of the errors intercepted before they example, worked at least 36 hours per week providing direct reached patients involved ordering errors, incorrect dispensing patient care as a critical care staff nurse on a specific unit and of medications, and allergies that were overlooked when not employed as a member of a hospital float pool or nursing medications were ordered and/or dispensed (see table 5).
agency. Nurses who were employed in specialised roles such asadvanced practice nurses, nurse clinicians and nurse managers The number of discovered errors did not differ significantly with regard to the critical care unit (p.0.2) or the hospital size Eligible participants received two 14-day logbooks, directions for recording information in the logbooks, and prepaidenvelopes to return the completed logbooks. A modified Dillman method14 was used to increase subject participation Our present findings, combined with earlier findings from the rates. Participants were paid $5.00 for each completed logbook Staff Nurse Fatigue and Patient Safety Study,9 16 suggest that page, with the maximum payment being $140.00. The study critical care nurses have an important role in maintaining the was approved by institutional review boards at the University safety of seriously ill patients. The 502 nurses participating in of Pennsylvania and Grand Valley State University.
the study reported catching themselves making an error on 350occasions,9 intercepting a colleague in the process of making an error on 43 occasions, and discovering an additional 324 errors The data from the study instruments were first summarised made by other staff members. Some errors, such as discovering using descriptive statistics and frequency tables. All narrative that an incorrect medication had been dispensed by the statements regarding discovered errors were transcribed verba- pharmacy or that an inappropriate dose of a particular tim. These errors were then classified into five categories using medication had been ordered, were intercepted before they the procedure developed for studying errors and near errors reached the patient. The majority of errors (88%), however, during the Staff Nurse Fatigue and Patient Safety Study.15 16 were discovered only after they had occurred.
Using exemplars to illustrate each type of discovered error, the Medication errors, although the most common type of error principal investigator and two nurse researchers with expertise discovered by participants in this study, are not the only types in critical care nursing classified all of the discovered errors into of error that occur in a hospital setting. Several studies have one of five mutually exclusive error categories (medication, shown that equipment-related errors, procedural errors, chart- procedural, charting, transcription and unable to classify ing errors, and errors related to diagnostic studies and Qual Saf Health Care 2008;17:117–121. doi:10.1136/qshc.2007.022699 Number and types of error discovered by 502 critical care nurses Coworker about to give medications to wrong patient at 4 am Antibiotics given to wrong patient twice, at noon and 6 pm Found lactated Ringer’s solution hanging on acute renal failure patient Pharmacy sent clonidine instead of Klonopin [clonazepam] [Doctor] ordered three medications patient was allergic to Pharmacy sent wrong antibiotic dose, label was right. Drug sent back to pharmacy Found insulin drip hanging on a patient that was a different mix/ratio than had been hanging earlier, patient was receiving four times the ordereddose [of insulin] Dialysis patient had received nafcillin 2 g IV q6 instead of 1 g as ordered for 3 days Patient received 12 500 U bolus of heparin, patient ended up going back to OR Patient with CHF to be receiving [IV] fluids at 21 cc/h, found fluids at rate of 121 cc/h when I took over care of patient at 11 pm Doctor wrote order for medication to be given IV, drug has caused fatalities when given IV RN wanted to change IM phenobarbital to IVP in patient with subarachnoid bleed Scheduled mineral oil at the same time as Synthroid [levothyroxine], meds hadn’t been staggered to allow absorption Post op pt was supposed to have Celebrex [celecoxib] before knee surgery—med given [after surgery] IV push med attached to line but not infused Dose of medication scheduled for 4 pm not given, found at midnight and given Patient on insulin drip, blood sugars should have been obtained every hour Respiratory [therapy] did not give scheduled treatment to [patient with] COPD Received patient from OR, medications (Dobutrex [dobutamine] and epinephrine) not infusing, stopcock turned the wrong way Someone gave a sickle cell crisis patient a tray without changing his 50% Venturi mask to nasal cannula, O2 saturation [dropped to] 69% in15 minutes and c/o pain Anesthesiologist gave Neo-Synephrine [phenylephrine] bolus for low blood pressure when the arterial line was kinked, patient’s BP was okay 7:20 am found IVP/ventriculostomy was clamped and probably clamped from 11 pm to 7 am as no CSF drainage during that time and had 140 ccdrainage during preceding shift Speech therapy [sic] changed the angle of the head of bed on patient with ventriculostomy Respiratory therapy [sic] over-stimulated closed head injury patient with suctioning, ICP into 40s, patient became bradycardic Found IV infusions of isotropic agents flowing out an open stopcock onto floor Nitric oxide tank empty. Respiratory therapy did not switch tanks correctly, patient without nitric oxide for 10 minutes, called respiratory therapysupervisor Agency RN taking care of a patient with a blood sugar of 23, not aware of hypoglycemic protocol, waiting for [doctor] to call back, I started D50.
Nurse did not write correct insulin order; wrote 5 U, supposed to be 15 U Orders on medication administration record had added a zero to a dose of Decadron, increasing its dose 10 times more than ordered Night nurse (who worked a 16-h shift) transcribed medication order incorrectly on MAR Order for KCl written for today only X2, transcribed as BID Incorrect order entry by unit secretary. Insulin sliding scale transcribed with wrong type of insulin MI pt left off O2, but RN had charted that O2 was in useNight RN charted wrong dose of dopamine drip, caught it at 8:15 am procedures are common.4 17 18 Almost a third of the errors this study were critical care units that involve high-alert discovered by participants involved procedural errors. Some of medications and intricate calculations, complex care and special these procedural errors were relatively minor (eg, pharmacy procedures, it was not surprising that the type and frequency of failing to pick up medications that had been discontinued) errors made and discovered were similar across units. Other whereas others (eg, injecting a medication through an arterial researchers have documented that critical care units are line or a speech therapist changing the elevation of the head of extremely busy environments, observing on average 187 the bed for a patient with a ventriculostomy) could have activities per patient per day.8 In addition, processes for harmed the patient had they not been intercepted. Other medication administration and healthcare procedures are procedural errors discovered by critical care nurses that could similar across healthcare institutions despite their organisa- have resulted in serious adverse effects included excessively tional size. These findings suggest that system and process- vigorous suctioning in a patient with an increased intracranial related factors should be examined for their role in error pressure and failure to provide a nasal cannula to a patient in prevention, discovery and correction. Finally, future studies sickle cell crisis to increase oxygenation while eating.
should determine if high workloads and fatigue impair critical According to the results of this study, there are no differences care nurses’ vigilance and alertness to prevent, discover and in the type and frequency of errors discovered by critical care correct errors made by themselves and other members of the unit or hospital size. Inasmuch as all of the units involved in Qual Saf Health Care 2008;17:117–121. doi:10.1136/qshc.2007.022699 Pharmacy sent wrong antibiotic dose, label was right. Drug sent back to pharmacy Pharmacist dispenses wrong dose of Solu-Medrol [methylpredisolone] [Doctor] ordered three medications patient was allergic to Doctor wrote order for medication to be given IV, drug has caused fatalities when given IV Clonazepam dose was too high, called to get dosage reduced Doctor ordered 35 cc bolus of D10W for low chemstrip on infant weighing 1.75 kg (protocol is 2 cc/kg).
Speech therapy [sic] changed the angle of the head of bed on patient with ventriculostomy Respiratory therapy [sic] over-stimulated closed head injury patient with suctioning, ICP into 40s, patient became bradycardic Nitric oxide tank empty. Respiratory therapy [sic] did not switch tanks correctly, patient without nitric oxide for 10 minutes, calledrespiratory therapy supervisor Another RN took a verbal order for Tylenol 3 [paracetamol and codeine] on a patient with history of anaphylaxis to codeine Patient with CHF to be receiving [IV] fluids at 21 cc/h, found fluids at rate of 121 cc/h when I took over care of patient at 11 pm Night shift medicated patient with a med that was due at 9 am today and it is only given only 7 days, so an extra dose was given Student nurse, orientee, new staff member New nurse had patient with SBP in the 60s and on Cardizem [diltiazem], nurse didn’t know to turn off Cardizem and start dopamine Agency RN taking care of a patient with a blood sugar of 23, not aware of hypoglycemic protocol, waiting for [doctor] to call back, Istarted D50.
Orders for evening potassium supplements accidentally removed from Kardex by secretary Incorrect order entry by unit secretary. Insulin sliding scale transcribed with wrong type of insulin During a code a drip was given out of sequence Under dosing of labetalol drip on hypertensive, haemorrhagic CVA patient Antibiotics ordered for 24 h were transcribed wrong, resulting in extra doses Although critical care nurses reported discovering more errors American nurses described in the National Sample of Registered made by others (n = 367) than catching themselves about to Nurses19 and an earlier sample of hospital staff nurses,20 as well make an error or actually making an error,9 it is possible that as representative of the membership of the American they discovered and corrected more errors than were reported in Association of Critical Care Nurses (J Medina, personal their logbooks. Because participants recorded information about communication, 2002). Although our response rate (43.7%) is errors in their logbooks at home after the end of their work lower than usually reported for surveys of healthcare provi- shift, it is quite possible that they forgot about some of the ders,21 this study required more effort than the usual survey errors they discovered and corrected several hours earlier.
since subjects were required to respond to between 17 and 40 The relatively small number of participants and low response items every day for 28 days. Because of the heavy subject rate may limit the generalisability of these findings. However, burden associated with this study, it is possible that those the nurses who participated in this study are similar in terms of participating in the study may not be representative of the age, gender and ethnicity to the probability-based sample of majority of critical care nurses. Since there were no differences Types and origin of errors discovered by critical care nurses Qual Saf Health Care 2008;17:117–121. doi:10.1136/qshc.2007.022699 Examples of errors intercepted by study participants Pharmacy sent IV fluids labeled with my patient’s name but ordered for a different patient with the same last name An order for Ativan was written in the wrong patient’s chart Patient has asthma, sotalol was ordered, [doctor] notified of asthma, sotalol discontinued Co-worker was about to give sublimaze instead of soluitrex Pharmacy sent Norcuron [vecuronium] drip instead of morphine drip Stopped nurse from giving a medication that patient was allergic to Pharmacy dispensed the wrong dosage of a medication, caught it when I was about to give it to patient Nurse was about to give double dose of Ativan to a patient Checked dosage of digoxin, nurse was about to give 0.5 mg IV instead of 0.25 mg IV Discovered Narcan [naloxone] vials that had expired 2 months ago Blood bank sent incompatible blood, I did not give it, and sent it back to blood bank Stopped RN (recent grad) from administering a med through an arterial line Another RN was going to hang a unit of packed red blood cells on a new patient whose temperature was 102.5 without calling the doctor first (asrequired by unit policy) Pharmacy not removing medications that were discontinued Stopped a new ICU RN from doing a cardiac output and calculating other hemodynamic parameters before a chest X-ray was done to confirmplacement [of Swan-Ganz line] Found tubes of morphine sulphate 5 mg in patient drawer without a label RN flushing Quinton catheter was going to use 10 000 U heparin instead of 200 U heparin Order incorrectly transcribed and patient could have been overdosed A zero had been added to a dose of Decadron in the medication administration record, increasing its dosage to 10 times that ordered Type of errors discovered by critical care nurses employed in Potter PA, Perry AG. Fundamentals of nursing, 6th edn. St. Louis: Elsevier Mosby,2005.
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experience, etc., between responders and non-responders (those Scott L, Rogers A, Hwang W-T, et al. The effects of critical care nurse work hours onvigilance and patient safety. Am J Crit Care 2006;15:30–7.
who were interested and eligible to participate, but did not Kellogg VA, Havens DS. The shift coupon: an innovative method to monitor adverse return any logbooks) we believe that the likelihood of a response events. J Nurs Care Qual 2006;21:49–55.
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the nurses could intercept several errors before they reached the Clarke SP, Sloane DM, Aiken LH. The effects of hospital staffing and organizational patient, the nurses were particularly effective at discovering and climate on needlestick injuries to nurses. Am J Public Health 2002;92:1115–19.
Dillman DA. Mail and telephone surveys: the total design method. New York: Wiley, correcting errors that had been made by other nurses and other members of the healthcare team. Acknowledging the existence Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors and near errors and effectiveness of this safety net is crucial; without reported by hospital staff nurses. Appl Nurs Res 2004;17:224–30.
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finding the root cause of errors more challenging and perpetuate Wright D, Mackenzie SJ, Buchan I, et al. Critical incidents in the intensive therapy a culture of blame. It is hoped that this study will provide a Flaatten H, Hevroy O. Errors in the intensive care unit (ICU). Experiences with an catalyst for future investigations and interventions that will anonymous registration. Acta Anaesthesiol Scand 1999;43:614–17.
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Qual Saf Health Care 2008;17:117–121. doi:10.1136/qshc.2007.022699

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