Dismantling Nursing’s Catch-22

(Nurse.com) Victoria L. Rich, RN, PhD, FAAN, chief nurse executive at the University of Pennsylvania Medical Center and an associate professor at the school of nursing there, recalls working at a hospital in the 1980s where a nurse who made three medication errors in one year automatically was fired. In such a fearful environment, few nurses wanted to report errors, Rich said, referring to those days as “the dark ages.”

In the past 15 years, as a preponderance of evidence shows the harm to patients from medical errors and the need to shed light on how and why such errors occur, more hospitals are trying to shift from punishing individuals for honest mistakes to using error reports as evidence to change systems, making it harder for clinicians to make errors and easier to catch mistakes before they cause harm. But the process of creating trust and a true culture of safety is not easy, said Ronda Hughes, RN, PhD, MHS, FAAN, associate professor at Marquette University College of Nursing in Milwaukee, Wis. It requires long-term hospitalwide commitment, strong leadership and a lot of time.

“It’s something you have to do for years on end,” said Hughes, who was a senior health scientist administrator for the Agency for Healthcare Research and Quality and works as a consultant for the Labor Management Institute in Minnesota. “It’s not something you can do for weeks or even a year.”

Haunted by the past

Even in hospitals that emphasize systems change rather than blame, the punitive culture of the past haunts many clinicians and administrators, say Rich and other nurses who have studied error reporting. Though nurses may understand the benefits of reporting errors, studies show many do not do so for a variety of reasons. In their chapter on error reporting and disclosure for the AHRQ’s Patient Safety and Quality handbook for nurses, Hughes and Zane Robinson Wolf, RN, PhD, FAAN, note a preponderance of studies showing the main reason clinicians do not report medical errors or near misses is a fear of repercussions that include everything from reprimands to losing their licenses. A 2009 study of more than 3,500 U.S. med/surg nurses, published in Health Care Management Review, concluded “issues surrounding the balance between job duties and safety compliance and nurses’ reluctance to reveal errors continue to be problematic.” A 2010 study of nurses in Taiwan published in Nursing Outlook showed nearly half of those questioned said they had failed to report medication administration errors, mostly because of fear and concern for their nursing reputations.

Though Rich believes hospital cultures are changing, Hughes said many nurses still feel they could lose their jobs or licenses for making an error, even when the official policy is not to punish individuals for mistakes. Nurses also may fear “silent” repercussions — veiled threats or a cold shoulder — from physicians or fellow nurses if they’ve reported on someone else or judgment about their nursing skills if the error is their own, Rich and Hughes said. Hughes recently worked with a hospital where an error occurred and the staff immediately blamed one person for the mistake. The hospital had an official “culture of safety,” and it was clear a series of events had led to the error, she said. Nurse leaders eventually agreed to do a root cause analysis to find out how the mistake occurred, “but the first reaction was to blame the individual,” she said. “It’s not just healthcare; it’s society as a whole.”

Human nature is to immediately find someone to fault for a mistake. In hospitals it is easier to blame a single nurse than 50 different organizational factors, she said, because it’s easier to reprimand or remove one person than to investigate and perhaps change 50 different systems.

The burden of reporting errors, especially medication errors, falls mainly on nurses because they are the last line of defense for patients, said Kathleen Burke, RN-BC, BSN, who chairs Patient Safety Fellows, a group of staff nurses devoted to patient safety issues at the University of California San Francisco Medical Center. Even when the initial error is committed by a pharmacist or physician, the nurse is the one who must take the time to report it and shoulder the risk of getting blamed for it, she said.
Many clinicians find the reporting process an annoying interruption in a busy day, Rich said. “Every system that we have to report errors is still time consuming to do when you are already under pressure,” she said. Some nurses wait to fill out error reports at the end of their shifts, when the information is no longer fresh in their minds. “We still struggle with how to do this easily.”

In some cases, nurses may not understand what constitutes a reportable error, especially if no harm is done, Hughes said. Numerous surveys of nurses about what constitutes a medication error show that though most believe a skipped medication is an error, a medication given an hour late or delayed because a patient was off the unit does not need to be reported. But if the medication is not being given as prescribed, it should be reported, Hughes said, so investigators can determine why it is not being given as it should be.

Make improvements, not just reports

Burke, who has worked as a reviewer of medical error reports and understands their value, believes nurses would be more willing to report errors and near misses if there were some feedback showing their reports actually were helping make changes and improving patient safety. But often the nurse never hears back about it, she said. In some cases, after many error reports nothing seems to change, even when nurses see an obvious problem. “What’s more data going to tell us?” Burke said. “When do these reports actually change or improve systems?”

Error reporting is important in figuring out where and how to make improvements, say nurses involved in error reporting and patient safety, and hospital policies do change as a result of error reporting. Kathleen Capitulo, RN, DNSc, FAAN, CNE at the JJ Peters VA Medical Center in the Bronx, said her facility received numerous reports of medication errors involving medication carts, which pharmacists had to chase down to fill, resulting in missed or delayed medication administration because the drugs nurses needed were not in place. Eventually, this led to the creation of wall carts at the bedside, which have proved considerably easier for pharmacists to fill and nurses to use immediately, Capitulo said.

At Massachusetts General Hospital in Boston, reports from nurses about patient falls led to a program that reduced the hospital’s fall rate, said Keith Perleberg, RN, MDiv, director of the hospital’s patient care services office of quality and safety. A nurse’s report of a malfunctioning blood pressure monitor led to an investigation, and the manufacturer eventually changed the way it produced the machines. A report of leaking IV tubing led to nurses working with the vendor to improve the product. Both cases involved tiny malfunctions, Perleberg said, and could have been skipped over by busy nurses. But the nurses talked to each other and decided it was important to make a report. “They encouraged each other,” he said.

The most important component of encouraging error reporting is good and consistent leadership, Hughes said. “If you don’t have strong, effective leadership that acts with integrity every day, it will inhibit you from reaching the culture of safety. Effective leadership leads by example.”

Rich rewards staff members who report near misses — which she calls “good catches” — with things such as movie tickets or cafeteria coupons and lets the rest of the hospital know about their achievements. “You need to celebrate when a nurse catches something that could have harmed people,” she said. Such rewards and public praise not only let others know it’s OK to report errors and near misses, but also creates trust between clinicians and their bosses, she said. Instead of fearing punishment, clinicians know they will be recognized for their efforts.

It’s also important for administrators to realize clinicians who make an error that causes serious patient harm often are traumatized by the event, she said, noting in several instances, nurses have committed suicide after making serious errors. Rich said she insists on counseling for employees who are involved in serious errors and lets them know the hospital will back them up with legal support if they need it.
MGH, as part of creating its “just culture,” has implemented a number of changes in recent years, Perleberg said. Those who submit error reports receive an email thanking them and saying the report has been read. Nurses are encouraged to share stories of near misses and talk about the steps they took to avoid patient harm. Staff members are encouraged to report disruptive behavior by colleagues, patients or families as incidents that compromise patient safety. “Our premise is the more fearful people are, the less they will communicate,” Perleberg said.

Like Rich, he remembers those more fearful days when error reporting caused great anxiety. When he completed incident reports as a new nurse, he said, “I always had a little fear inside that my boss would call me in and say, ‘You’re not doing a very good job.’ The whole culture around safety event reporting was never talked about except that if something was wrong, you completed a report.” No one mentioned how the reports would be used to make life better and safer for patients, he said.

At MGH, Perleberg believes those attitudes have changed throughout the hospital. Some months ago, when a bedside monitor alarm was discovered in the off position and a patient died, the ensuing investigation did not focus on blaming someone who might have turned it off, he said. “We were on a hunt to improve the system.” Hospital administrators decided to make the event public, alerting other facilities to the importance of having monitor alarms that could not be turned off, at a volume clinicians could always hear. “We bear the responsibility of sharing what we’ve learned,” Perleberg said, “even when we’ve learned it painfully.”

Steps to encourage error reporting

  • Make it clear staff will not be punished or blamed for errors or near-misses and reporting errors improves patient safety.
  • Have a written policy in place for reporting and investigating errors, and make sure all supervisors and administrators understand this policy and follow it consistently and reward good catches.
  • Give feedback on error reports — both immediately, by acknowledging receipt of the report, and long-term, by sharing data on reported errors and changes the reports may lead to, such as a new policy or correcting faulty equipment.
  • Let staff know that if they make an error that harms a patient, administrators will provide emotional and legal support.
  • Model transparency on a hospitalwide basis — if an error is committed, don’t try to cover it up. Report it to the appropriate authorities and share results of any investigation with other facilities.
  • Educate staff about what constitutes reportable errors and near misses, even when no harm is done to a patient.
  • Work with staff to improve error-reporting process to make it as easy as possible for a busy clinician to report an error.
404