Procedural errors, charting errors also significant
A recent study of errors and near errors by hospital staff nurses confirmed some pre-existing beliefs, but also contained some surprises, according to one of its authors.
The study, published in the November 2004 edition of Applied Nursing Research, showed nearly 30% of the hospital staff nurses who participated reported making at least one error during a 28-day period; one-third of the nurses surveyed reported a near error, in which they caught themselves before they were about to make an error. The study was funded by the Agency for Healthcare Research and Quality.
Among the surprises noted by co-author Ann E. Rogers, PhD, RN, associate professor at the University of Pennsylvania School of Nursing in Philadelphia, was the variety in the major sources of errors.
"Previous studies had always taken note of medication errors, and there’s a good reason to focus on them, but that’s only part of the picture," she says. "Only 58% of the errors reported in our study were related to medication administration."
The study showed the second most common type of errors were procedural errors (18.4%), followed by charting errors (11.9%).1
The authors reviewed logbooks maintained by 393 nurses who answered these questions:
- Did you make any medication or other errors today?
- Did you catch yourself before you were about to make an error today?
If nurses responded yes to these questions, they were asked to describe what happened. Depending on their work schedule, nurse participants were asked to complete a maximum of 40 questions per day, along with questions about sleep/wake patterns, mood, and caffeine intake. On their days off, they only responded to the latter questions.
The nurses in the study reported a total of 199 errors and 213 near errors during the data collection period. The authors point out that when these results are extrapolated to a one-year period, errors and near errors for this sample of nurses would total nearly 5,000 incidents.
Although 61.3% of the nurses reported only one error during the data-gathering period, 45 nurses reported making between two and five errors, and one nurse reported a total of eight errors.
Similarly, 80 nurses reported the interception of at least one of their own errors; however, 37% of the nurses stated that they stopped themselves from making between two and seven errors. One nurse reported intercepting a total of nine of her own errors.
The procedural errors reported in the study referred to situations where nurses actually followed the wrong procedure or did not follow standard practices, Rogers explains.
"One was working in dialysis and made a math error, another forgot to put on a grounding cautery pad, a third forgot to put in a Foley catheter — all things that go against accepted practice," she notes.
Many transcription errors were reported because, as Rogers points out, only a relatively few hospitals currently use computerized physician order entry (CPOE). "There’s still a lot of [hand] transcription, and there are lots of ways things can get incorrectly transcribed," Rogers observes. "And computerized charting is supposed to make things expeditious, but one nurse reported she mistyped something but couldn’t get it corrected without help. Other times, computers went down."
Errors such as those are not necessarily going to hurt patients, Rogers continues, "but it does suggest a level of chaos going on. For example, late meds usually won’t hurt the patient, but it can easily happen when one patient gets very sick and the nurse can’t get to other patients."
Nevertheless, many errors do get caught. For example, Rogers recalls, one nurse prepared an IV incorrectly but noticed it was the wrong color. Another realized she initially had mistaken two "p" containers, Pepcid and Pitocin, but realized it as soon as she grabbed the wrong container.
"That’s what you want — an alert, vigilant care provider," Rogers adds. "We’re all human."
From this and earlier studies, Rogers is convinced that one strategy that could help lower error rates is reducing distractions. "This is critical for people in high-risk occupations," she asserts. "Most other occupations of this kind operate in an environment that is very quiet, with few distractions. Nurses, however, perform in a very chaotic environment."
Some facilities, Rogers says, have made it possible for nurses to prepare meds in the middle of a hallway, away from distractions. In a small study, the nurses who prepared meds were provided with brightly colored vests, and other staff were instructed not to disturb them unless there was an emergency.
"Minimizing the distractions would help a lot in reducing errors. Just think of traffic controllers, or pharmacists mixing meds," she continues. "It’s very hard to maintain accuracy when you are multitasking; we need to manipulate the environment to make things easier for nurses to do."
In terms of reducing medication errors, purchasing decisions can make a huge difference, Rogers says.
"We had a number of heparin-related errors. When I first graduated [from nursing school], we knew to watch heparin closely, because it came in two different strengths — 1,000 units and 10,000 units per cc. It’s legitimate to have both, but they are known to be easily mixed up. If the pharmacy can draw it up downstairs, your error rate really drops," she adds. "And if the pharmacy buys the pre-mixed solution, it drops to less than 1%. So if purchasing would buy the pre-mixed, or if the pharmacy did more mixing of IV flush solutions, it would reduce the risk of that error."
At first glance, this approach might seem to be much more costly, she concedes. "But if you factored in the nurse’s time for mixing and think about the fact that you don’t have enough nurses, it might balance out the cost."
1. Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004; 17(4):224-230.
Need More Information?
For more information, contact:
• Ann E. Rogers, PhD, RN, Associate Professor, University of Pennsylvania School of Medicine, 420 Guardian Drive, Philadelphia, PA 19104. E-mail: firstname.lastname@example.org.