Nurse Likelihood to Report a Medication Error

Nurse Likelihood to

Report a Medication Error

Francine Kingston, DrPH, MSN, RN-BC

Director Clinical Training & Development

Texas Children’s Hospital

Houston, Texas USA

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Texas Children’s Hospital Houston, Texas

•Free-standing, not-for-profit woman’s and

children’s hospital

•Magnet designated since 2003

•Ranked 4th Best Children’s Hospital by US

News & World Report

•25,966 Admissions

•656 Beds

•2300 RN employees

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Medication Error-Nurses ARE the Sharp End

•Process of 40-60 steps (Botwinick,

Bisognano, & Haraden; 2006)

•Any 50 step process will be completed

with no error 61% of the time (Botwinick,

Bisognano, & Haraden; 2006)

• Intercept 86% of all medication errors (Hughes & Ortiz, 2005)

•One process failure per hour (Edmondson,

2004)

•Find a quick fix work-around 93% of the

time (Edmondson, 2004)

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Nurses ARE the Sharp End

•Most trusted profession

•Multitask beyond brain’s capacity – reprioritize constantly

•Error under-reported by 50-90% (Barach, 2000)

•To learn from error we must report (Assumption)

•Temptation is to not report: too busy, shame, trivialization,

fear of reprimand, no harm so why report – anecdotal

•More likely to report serious error – only 31.7% report

breast milk connected to IV tubing if error caught before

reaching the patient ( Taylor et al, 2004)

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Purpose

•To learn from lived experience

•Better understanding of contributing

factors

• Interventions can be identified

•Facilitate psychologically healthy

inner resolution to turmoil

• Increase reporting

• Increase learning

•Reduce possibility of future error

• Improve patient safety

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Error Continuum – Researcher’s Depiction

ERROR PREVENTION

• FMEA to proactively address risk points

• Apply knowledge of human factors in

prevention strategies

• Uncover and eliminate latent factors

• Forster a blame-fee environment

• Establish an event reporting system

ERROR MANAGEMENT

• Ensure patient needs are met

• Evaluate patient harm

• Gather knowledge surrounding the error

• Support of nurse involved

• Disclose to patient/family

• Address system factors

PRE-REPORTING Potential for Cognitive Dissonance

Prescribe/Prepare/Package/Deliver/Administer Error Report

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Today’s Objectives

1. Describe the study’s research

question and methodology.

2. Synthesize the results of this

study into a set of implications

for nursing leaders in both the

practice and academic arenas.

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What factors contribute to the

likelihood that a pediatric nurse will

report a medication error?

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METHODS •Design: Qualitative

•Setting: Children’s Hospital Southwest USA

•Population: RN

•Recruitment: Poster flyer

•Sampling: Purposive

•Data gathering: Structured group interviews/Interview guide

‐ Individual vs. Group interview

‐ Hypothetical questions – reportable conduct supersedes research confidentiality rules

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FROM “Tell me about a time when you…”

“What feelings and emotions did you

experience…”

TO

“What do you think a nurse experiences…”

“What do you think runs through a nurse’s

mind upon realizing…”

“How does a nurse react…”

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METHODS •Group size: Ideal 6-10 (Morgan, 1997)

‐Actual 2-9

•Group composition: Should share common set of norms /experiences

‐Homogeneous on many factors

‐General vs. special care – drove up “n”

•Group familiarity: common practice is groups who do not know one

another (Morgan, 19997)

‐Richness of information and interactions (Jato, van der Straten,

Kumah, & Tsitol; 1994)

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METHODS: Sample Number of groups and sub groups: General Care, Special Care, Combination

• One of each sub group?

‐ Will not know if perspectives shared are due to group composition or a unique group

dynamic

• Two of each sub group?

‐ Similar outcomes would probably confirm that composition of unique dynamics were

not at work (Morgan, 1997)

• Three of each sub group? Nine (9) total group interviews

‐ More dependability (reliability)

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METHODS: Data Collection After IRB approval

• Structured group interviews private conference room away from patient care areas

• Consent and demographic forms

• Animal identifiers

• 2 digital recorders

• One moderator

• One scribe – attention to group dynamics, tone, body language, domination

• Conversational probes

• Attention to reflexivity; no judging tone or expression

Rich discussion, synergy, respectful interaction, engaged participants

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METHODS: Data Analysis & Management

• Verbatim audio recording transcription

• Verbal and non-verbal aspects of conversations

• Group dynamics and energy around topics

• Transcripts coded and then analyzed for

emerging themes

• Self-reporting bias – aware of possibility

• Field notes reviewed immediately

• Reflexivity

• Recordings and transcription reviewed for

accuracy

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RESULTS - Demographics •Sample

•Mean age

•Education level

•Certification status

•Mean years experience

•Ethnicity

•Made a med error

•Made a med mistake

•Considered not reporting

•54

•39.8 years

•67% baccalaureate

•61%

•15.1 years

•No difference

•92.6%

•98.1%

•63%

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RESULTS - Demographics

Age ≥ 40 and <

40 years

Years worked in

pediatrics

Special care nurses were younger

•Chi-square Fisher’s Extract Value 8.263, p=

0.017 (two sided)

General care nurses worked an average of 9

years longer than special care nurses

•One-way ANOVA; Bonferroni test of multiple

comparisons mean difference score 9.3179,

Standard Error 3.1878, p= 0.05.

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RESULTS – Themes that Emerged

The nurse’s foremost concern is the wellbeing of the

patient.

Immediate and instantaneous fight or flight.

Fear, shock, anxiety, bewilderment, sinking feeling, sense of

devastation, HR increase, chest pounding, perspiration,

nausea.

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Managers are key. If managers are supportive in response to

error, a nurse is likely to report again.

‐ “…acknowledge their discomfort…check on them periodically to

make sure that they are doing okay…”

‐ “…loop back… on what a difference their reporting made in the

process…” (Nurse 2, Group 1)

Nurses want to be held accountable for their errors.

“Hold us accountable, but be human.” (Nurse 4, G7)

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Nurses are more likely to report in an environment

perceived as non-punitive.

‐“…if they could say to their manager, ‘I really messed this up.

What do I need to do?’ and not feel like they were going to be

talked bad to or yelled at or something really ugly happening

to them… they might speak up.” (Nurse 4, G7)

‐Fears – loss of license, career, job, livelihood

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Nurses struggle with wanting to be perfect.

‐ Introspection, self-talk, self-doubt, question own competence,

shaken self-confidence, shock and disbelief.

‐“I think we’re under the gun so much to meet schedule

deadlines and so many other things that we have to do

throughout the course of a shift…our expectation is that we

do everything perfectly.” (Nurse 1, Group 8)

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Nurses question their own competence after an error. ‐ Introspection, self-talk, self-doubt, question own competence, shaken self-

confidence, shock and disbelief.

‐ Nurses beat themselves up – heard over and over.

‐ “How could I have been so stupid to make a mistake? What was I thinking? Should I

be at this job giving dangerous drugs?” (Nurse 5, Group 9)

‐ “Oh my gosh. Am I not supposed to be a nurse?” (Nurse 6, Group 1)

‐ I can’t believe I did it. That was so stupid. That was dumb. I didn’t double check. I’m

always careful.” (Nurse 4, Group 7)

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Nurses need to regain Self-Worth and so engage in a

process of reconciling the dissonance between wanting to be

perfect and having made a medication error.

Nurses may rationalize or minimize (trivialize) the severity or

significance of the error in their own mind. ‐ “Oh, well, there was no harm done, so why do we have to report it?” (Nurse 5, G7)

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Self-Worth / Reconciling the dissonance

They may blame others.

‐ “I was devastated and scared and all that, but then on top there was

anger because it was ordered wrong by a resident, not caught by

pharmacy, dispensed wrong, and there it was. So then you’re angry,

and that’s just trying to diffuse some of the guilt because you feel

awful. ” (Nurse 6, G1)

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Self-Worth / Reconciling the dissonance

They may try to save face and avoid telling the truth.

‐Avoid telling patient and family, co-workers, physicians because of

potential loss of trust and respect

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Nurses take issue with the process of reporting.

•Lack of clear definitions

‐ Error vs. mistake; reach the patient vs. not reach the patient; harm vs. no harm;

incident vs. near miss

•Cumbersome procedures - Need to be efficient and private

‐ “…having to do it at the end of the day … You want to go home because you’re so

tired, and yet, you have to sit down and fill out this long process of reporting…

Because it’s really difficult to do it in the midst of patient care, because you get

interrupted, and then, of course, you worry about people looking at the screen… you

lock up…..you might lose your data…” (Nurse 1, G3)

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Nurses want to be involved in synthesizing error reports.

Nurses want to be involved in data analysis.

‐ “You know, I think another thing that might encourage nurses to report

would also be if there’s a circle back so that if that nurse felt like she’s going

to report that, and then she’s going to get feedback about how that

information was used to change a process… you as a nurse would feel so

good that you were part of the process of making something safer.” (Nurse

4, G6)

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VALUE •Nurses want to be part of the solution and help us learn

from error.

•A nurse’s first concern is for their patient.

•Themes emerged as powerful factors in likelihood to

report:

‐ Culture of blame

‐ Managers are key

‐ Struggle with perfection

‐ Reconciliation to regain self-worth

‐ Cumbersome systems of reporting

‐ Need to be involved in data analysis and need for feedback

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LIMITATIONS

•Limited transferability /

generalizability

•Self-selection bias /

reporting bias

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Today’s Objectives 1. Describe the study’s research question and

methodology.

What factors contribute to likelihood to report…

2. Synthesize the results of this study into a set of

implications for nursing leaders in both the practice and

academic arenas.

Next…

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CONCLUSIONS

1. When an error occurs, it is a

very stressful time for a nurse

2. Hospitals have an opportunity

here; and so do our schools of

nursing.

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Implications for Schools of Nursing and

Heath Care Organizations Curricula

•Theories of high hazard industries, human

performance, natural accident theory, high

reliability organization theory, system

complexity, production pressures, attribution

bias, trivialization, dissonance, and the

psychology of human reaction to error

including the strive for perfection should be

incorporated into undergraduate curricula

and reinforced in health care organizations.

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Heath Care Organizations Managers •Education must include the natural human

tendency to attribute blame and how we must

overcome that attribution bias to uncover all

contributing factors to error.

•Education and training should be available to

managers who immediately counsel the nurse

who has made an error do demonstrate more

compassion and fairness, acknowledging this is

a process with many opportunity for system

failure so that less blame is perceived by the

nurse.

•Text [Arial 22pt]

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Heath Care Organizations Reporting Process

•Procedures used in reporting should be

evaluated to promote the most efficient and

most private process possible.

•Promote reporting on near misses in

addition to error.

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Heath Care Organizations Synthesis, Interpretation, and feedback

•Structures and processes should be put in

place to engage the bedside nurse in

discussing error, and in synthesizing and

interpreting the data around medication

error; and feedback provided to

demonstrate that organizations can learn

from error and change long standing

traditional practices.

• Include interprofessional solutions

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Today’s Objectives

1. Describe the study’s research

question and methodology.

2. Synthesize the results of this

study into a set of implications

for nursing leaders in both the

practice and academic arenas.

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TRANSLATE THIS Model the Way to:

•Make curricular enhancements around theoretical foundations in

schools of nursing;

•Empower our nurse managers to make a difference - educate on natural

attribution bias; provide training on how to “hold me accountable but be

human”;

• Improve reporting process definitions, efficiencies, privacy; and include

near misses; and

•Engage your nurses – share event data, involve in interpretation and

analysis, and close the communication loop by providing feedback on

process change.

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Heath Care Organizations Curricula

•Theories of high hazard industries, human

performance, natural accident theory, high

reliability organization theory, system

complexity, production pressures, attribution

bias, trivialization, dissonance, and the

psychology of human reaction to error

including the strive for perfection should be

incorporated into undergraduate curricula

and reinforced in health care organizations.

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TRANSLATE THIS Nurse Leaders around the globe must Model the Way to:

•Make curricular enhancements around theoretical foundations in

schools of nursing;

•Empower our nurse managers to make a difference – Give them the

tools : educate on natural attribution bias; provide training on how to

“hold me accountable but be human”;

• Improve reporting process definitions, efficiencies, privacy; and include

near misses; and

•Engage our nurses – share event data, involve in interpretation and

analysis, and close the communication loop by providing feedback on

process change.

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TRANSLATION BEGINS HERE

“Be more transparent, talk about errors more,

the message should be that we should not be ashamed.”

Powerful… But are we listening?

Study results are all wrapped up in this…perfection, blame, shame, self-

worth, managers, engage nurses in interpreting, provide feedback.

As leaders – what should our own behaviors be?

What should our nurses be experiencing?

We can control this if we choose to and it has to start in our schools of

nursing and needs to be the lived experience in our health care facilities.

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SUMMARY - Nurses

•Take pride in healing and perfection;

•Are perceived as the most trusted and ethical profession;

•Are subject to their own needs for self esteem;

•Work with humans who have a natural tendency to attribute error;

•Work in cultures in which blame and shame are inherent even if those

cultures are improving;

•Work in systems that are complex, tightly coupled, requiring hand-offs

all day, with distractions and interruptions and problems to solve;

•Are fallible and will make mistakes;

•Will someday find themselves having to reconcile an error and needing

to come out of the experience with their self-worth intact but also having

learned from and having helped a system learn from the mistake.

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WANT TO LEARN FROM ERROR?

•Error we understand – system is complex, multiple contributing factors

•What we need to understand is: ‐ WE can help our nurses better understand this phenomenon that is

HAPPENING TO THEM

•Think we need to be perfect

•Humans attribute blame

•Humans experience dissonance and need to reconcile self-worth

•Need to be involved – want to contribute to improvement and feel like

“I’m not the only one”

“…message should be that we should not be ashamed.”

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This change is up to us …

Curricula – teach it

Health Care Systems –

reinforce it and live it

Thank you!

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Documents

Nurse Likelihood to Report a Medication Error