Mistakes Happen
A systematic approach
might help turn the tide

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Avoiding 'Oops!'

Though the Institute of Medicine report on medical errors stresses systematic changes, experts agree that individual nurses play key roles in preventing mistakes. "The onus of responsibility often ends with the nurse," said Hedy Cohen, RN, vice president of nursing for the nonprofit Institute for Safe Medication Practices in Huntingdon Valley, Pa. "They're supposed to track the physician's errors. They're supposed to catch the pharmacist's errors. They're supposed to catch their own errors. They're supposed to catch the patient's error. So they're in a real vulnerable position."

But nurses can reduce their vulnerability-and their patients'-by heeding the following advice for creating a safer environment:

Don't cut corners. "Everything is ASAP today," said Michelle Peterson, MSN, RN, president of Management and Practice Assessments, a Dallas-based ambulatory healthcare consulting company. "We're short of staff, we're having to do it faster, and the problem is that we cut corners. Then the potential for errors rises dramatically." She advises nurses to be assertive in demanding enough time to do a procedure correctly.
Speak up. "The ethical code for nurses requires that they report unsafe practices," said Carolyn Gunning, PhD, RN, dean of the college of nursing at Texas Woman's University in Denton. If you don't have the time, supplies, or whatever else to do your job properly, you need to report the situation to your supervisor immediately.
If you don't know, ask. "Check it out with a colleague," Peterson said. "I don't think it's a sign of weakness." Rather, you could be saving someone's life.
Keep your skills up-to-date. Knowing the right way to do something goes a long way toward avoiding mistakes, said Sally Raphel, MS, RN, director of nursing practice and director of the Safety and Quality Initiative for the American Nurses Association.
Join-or create-a patient-safety committee. Nurses are the primary patient advocates and should have a voice in any patient-safety forum, said Mary Wakefield, PhD, RN, FAAN, director of the Center for Health Policy Research and Ethics at George Mason University in Fairfax, Va., and the only nurse on the committee that compiled the IOM report on errors.
Include error reduction in the strategic plan of your unit. Patient safety shouldn't be an afterthought following a mistake, Wakefield said. Nurses should regularly look at error data, analyze it, and develop plans to prevent the errors from recurring.
Raise the issue of patient safety during any discussion of planned change. Change happens constantly, Wakefield said, but the dynamic environment it creates increases the potential for mistakes. "Patient safety ought to be a litmus test that gets raised in almost every meeting, no matter what the discussion. How will patient safety be impacted by what we're talking about?" she said. "Nursing should be that voice."
Change your mind-set. Instead of "passing meds," a task-oriented behavior, you should consider it "administering meds," a higher cognitive thought process, Cohen said. Continually ask yourself: Why is this patient getting this medication? Is this the appropriate amount? How should it be given?
Create a climate of support. "Nurses have to be supportive of themselves and others when they make an error, to realize that they're human," Cohen said. Nurse managers should thank staff for reporting errors and not record incidents in personnel files. Rather, they should look at systematic changes to avoid the error in the future. "Unless you remove the stigma of the error and evaluate what went wrong," she said, "it will continually repeat."

~ Anne Federwisch, OTR
 

By Anne Federwisch, OTR
February 7, 2000
Photo: Photodisc

To err may be human, but to die as a result of those errors has become a national epidemic. Medical mistakes result in 44,000 to 98,000 deaths annually—more than from highway accidents, breast cancer, or AIDS—according to the Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System, released in November 1999. While synthesizing the results of numerous studies on medical errors, the report also provides several recommendations for reducing those mistakes by 50 percent in the next five years.

The writers stress avoiding a punitive approach to error reduction, which treats those who make mistakes as social outcasts but does little to reduce future incidents, said Mary Wakefield, PhD, RN, FAAN, director of the Center for Health Policy Research and Ethics at George Mason University in Fairfax, Va. She was the only nurse on the IOM panel that authored the paper. "Rather, try to identify what within the system contributed to that error occurring, or didn't prevent it from happening, and how do we collectively prevent it from happening again," she explained.

Widespread response

The report garnered the swift attention of President Clinton, professional healthcare organizations, and safety advocates across the country. Clinton called for the implementation of patient-safety initiatives in health plans serving federal employees, a task force to analyze the report and make recommendations, and the use of $25 million by the Agency for Healthcare Research and Quality (AHRQ) to find a way to avoid healthcare errors. The American Nurses Association (ANA), the Institute for Safe Medication Practices, and others have testified before congressional committees to suggest ways to reduce errors.

"What nurses have known in their daily work as unsafe situations are being brought to public attention," said Sally Raphel, MS, RN, director of nursing practice and director of the Safety and Quality Initiative for the ANA, a program launched in 1994. The program has developed a nationwide database to collect, measure, and benchmark quality of care related to nursing, such as pressure ulcers, nurse satisfaction, staff mix, and nosocomial infections.

But the IOM's revelation of the magnitude of the problem caught many nurses' attention. "I was struck by one of the comments in the report that one of the biggest barriers to improving patient safety is the lack of awareness of the extent to which errors occur daily," said Carolyn Gunning, PhD, RN, dean of the college of nursing at Texas Woman's University in Denton.

The IOM recommends the creation of a National Center for Patient Safety within the U.S. Department of Health and Human Services, mandatory reporting of serious mistakes leading to death or injury, voluntary disclosure of less serious mistakes, and periodic re-examination of health professionals to ensure their competence and knowledge of safety practices.

Despite approving of its overall recommendations, Raphel faulted the IOM study for omitting a discussion of staffing issues as a major contributor to errors. "That is glaringly missing from the IOM report," she said. "It doesn't matter how many fail-safe computer systems you have or device fail checks, if you don't have the human element there of the experienced, knowledgeable nurse, errors will happen."

Making it mandatory?

Others have faulted the suggestion of mandatory reporting of serious errors leading to patient death or injury, including John M. Eisenberg, MD, director of the AHRQ. He heads the Clinton administration's review of IOM proposals.

Part of the problem with mandatory reporting, according to Gunning, is that the IOM can't control what happens with the information once it's reported. "People in the legal system want that data available, and they make use of it," she said. "What I hope doesn't get lost is the focus on the reporting for the purpose of making systems changes, rather than for the purpose of punishing."

The Institute for Safe Medication Practices also is against mandatory disclosure, said Hedy Cohen, RN, vice president of nursing for the Huntingdon Valley, Pa., organization. "We believe that when you make error reporting mandatory, people will begin to hide their mistakes. If we don't know what's going on in the hospitals, we can't correct it," she said.

Mandatory reporting was not an easy proposal for the IOM to make, Wakefield said. Much discussion centered on whether public disclosure of errors would be punitive or problematic, but the committee finally opted to side with the public's right to know. "We're talking about an extremely narrow band of problems that are reported [publicly]," she said. "We feel the vast majority of healthcare problems should be protected from disclosure."

Raphel also defends the mandatory requirement. "In the beginning, we think it would have to be mandatory in order for a true picture to be achieved and for there to be a change in behaviors-administrative as well as professional, clinical behaviors," she said.

Measuring competency

Another admittedly difficult suggestion is competency-based re-evaluation of health professionals, Wakefield said. "Much of what we're recommending isn't easy to implement, but we were really looking at threshold change," she acknowledged.

Although the National Council of State Boards of Nursing (NCSBN) does maintain a disciplinary database, tracking, or even quantifying, practice errors remains difficult, said Vickie Sheets, JD, RN, director of policy and credentialing. "You can't cubbyhole a disciplinary case for a practice error," she said. In such cases, nurses are rarely charged with just one violation, so one incident may result in a number of different charges entered in the database. Plus, terminology varies from state to state, further complicating the matter.

Sheets said that in light of the IOM report, the NCSBN is trying to find a way to effectively extract and track practice error information from its database. "The data is enmeshed and complex, but we're starting to look at practice error breakdown," she said.

Competency-based assessment is particularly difficult in nursing because of the wide diversity of practice, Gunning said. Though she thinks the concept is valid, she's troubled by its potential implementation. "I'm not sure that if you're going to try to measure someone's continued competence, you try to measure the practice they're performing today, or the one they might be performing tomorrow, or the one they were doing yesterday," she said.

No state has yet implemented competency-based license renewal requirements. Texas, like 25 other states, requires continuing education. But tracking of specific types of errors made is difficult to obtain. According to the Board of Nurse Examiners, far less than one-half of 1 percent of currently licensed RNs in Texas are sanctioned for medical errors annually.

The true test of patient safety is preventing medical errors before they reach patients, Cohen said. "Good practitioners do make mistakes," she said. "We're not taking the responsibility off the individual coming in, trying to do the best that they can." But the emphasis now should be on voluntarily reporting those errors, creating redundant systems to catch those errors before harm is done, and consequently creating a safer environment, she said.