Study examines nature and prevalence of errors in patient care

Cites complex and distracting work environment

A University of Pennsylvania School of Nursing study provides the first detailed description of the nature and prevalence of errors by hospital staff nurses. During a 28-day period, 393 registered nurses kept a detailed journal of their errors and prevented errors, referred to as near-errors. Thirty percent of the nurses reported at least one error during the 28-day period, and 33 percent reported a near-error. Although the majority of errors and near-errors were medication-related, the nurses also reported a number of procedural, transcription and charting errors. “Given the prevalence of other types of errors, an exclusive focus on medication administration errors, often a typical practice, may miss many important and potentially hazardous situations,” said Ann E. Rogers, an associate professor in Penn’s School of Nursing.

The findings are presented this month in the journal Applied Nursing Research and are derived from a previous study that examined staff nurse fatigue and patient safety. “Although nurses pride themselves on being able to juggle multiple tasks at once, too many distractions from multiple sources make errors inevitable,” Rogers said. “Other reports have shown that a nurse may be interrupted, on average, at least 19 times during a three-hour period by at least 13 different types of sources.” Approximately 33 percent of actual medication errors were because of late administration of drugs to patients, which in some cases was due to inadequate numbers of nurses on duty. In one example, a nurse reported a 90-minute delay in giving medications to one patient and a 40-minute delay to another because she could not leave the bedside of a third unstable patient. As hospitalized patients become more ill, with complex care requirements, and the nursing shortage intensifies, such situations may become more common.

Other errors can be attributed to workplace distractions. According to the participants in the study, frequent interruptions from staff, students or even the telephone made administering medications and carrying out other patient-care activities challenging. Procedural errors, such as omitting a routine task or making charting and transcription errors often arise from garbled communication within the immediate work area. While it might be impossible to avoid all distractions, the use of technology such as bar code medication administration systems and paperless charting systems have been shown to reduce errors. But such technologies are not widely used and are not user friendly.

The study itself demonstrates that nurses will report errors when they feel safe and when the reporting system is not burdensome. According to Rogers, it is important to acknowledge the vigilance and astuteness that led to the nurses catching many of their own errors before they reached the patient.

Michele C. Balas, a Penn Nursing doctoral student, and Linda D. Scott, an associate professor from Grand Valley State University, co-authored the study. Funding was provided by the Agency for Healthcare Research and Quality.