Nursing Errors

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Nursing Errors

• By Kristy Clark and
• Dawn Simon

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What is a nursing error?

• A mistake that is made by a nurse that
• Can affect the outcome of something
• Causes an adverse effect
• Is a result of poor judgment
• Is potentially irreversible
• Anoosheh, M., Ahmadi, F., Faghihzadeh, S.,
  Vaismoradi, M. (2008). Causes and management of
  nursing practice errors a questionnaire survey
  of hospital nurses in Iran. International Nursing
  Review, 55(3), 289.

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Ohio Law Regarding Nursing Errors

• According to the Ohio Board of Nursing, all
  licensed nurses should report errors.
• Unfortunately, Ohio law doesnt mandate that you
  report a medical error, therefore many go
  unreported.
• Its an RNs ethical obligation to report his/her
  errors as well as other nurses errors that are
  witnessed.
• Ohio Board of Nursing (n.d.). Chapter 4723-4
  standards of practice relative to registered
  nurse or licensed practical nurse. Retrieved from
  http//codes.ohio.gov/oac/4723-4.
• Karlsen, K., Hendrix, T., O'Malley, M. (2009).
  Medical error reporting in America a changing
  landscape. Quality Management in Health Care,
  18(1), 59-70.

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Types of Nursing Errors

• Medication administration
• Given at wrong time, wrong patient
• Lack of documentation of administration and given
  more than once
• Not given at all
• Given at incorrect site i.e. IM injection in a
  subcutaneous site.
• Calculation error
• Illegible penmanship and failure to obtain
  clarification
• Austin, S. (2008). Seven legal tips for safe
  nursing practice. Nursing 2008, 38(3), 34-39.
• Bohomol, E., Ramos, L., D'Innocenzo, M. (2009).
  
• Medication errors in an intensive care unit.
  Journal
• of Advanced Nursing, 65(6), 1263.

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Types of Nursing Errors (cont.d)

• Patient neglect
• Ignore what the patient is saying
• Perform duties beyond an RNs scope of license
• Failure to report and monitor for deterioration
• Communicating ineffectively with family and
  colleagues during transfer of care
• Careless documentation- inaccurate, not in a
  timely manner, and/or failure to document
  completely
• Austin, S. (2008 March). Seven legal tips for
  safe nursing practice. Nursing 2008, 38(3),
  34-39.

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Impact of Nursing Errors on Patients

• Patient dies
• Patients condition worsens
• Patient develops permanent disability
• Lawsuit

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Discipline R/T Nursing Errors

• Not all errors lead to punishment
• R/T not being reported
• No harm to patient
• Loss of RN license
• Suspension of RN license
• Incarceration
• Humiliation R/T your name, reason for
  losing/getting license revoked and reason for the
  punishment being published on the
  www.nursing.ohio.gov

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Causes of Nursing Errors

• Understaffed units
• Under qualified nurses
• Long shift hours
• Inadequate time available for proper nursing care
• Failure to follow requirements for continuing
  education

• Personal life interfering with professional life
• To stressed to think clearly
• Take on to large of an assignment
• Show up to work impaired R/T alcohol or drug use

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How Errors are Corrected

• Tell the patient about the error if coherent
• Notify patients family if patient is incoherent
• Report and properly document error in a timely
  manner
• Do everything possible to prevent adverse effects
  of error on patient

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How to Report an Error That You Witness

• Complete a complaint form located on
  www.nursing.ohio.gov under the forms tab
• Send completed form to the Ohio Board of Nursing
  via website listed
• Report to nursing supervisor
• If it was you that made an error, fill out an
  incident report via hospital protocol

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Nurses at risk

• New RNs with limited experience
• RNs who cannot say no
• RNs who work on a unit thats understaffed

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Are Medical Errors an Issue?

• Its suggested that the leading cause of death in
  the U.S. is preventable adverse events in the
  hospitals.
• The most common medical errors are medication
  errors
• Affect at least 1.5 million people each year
• Cost the health care system between 77 and 177
  billion annually
• More than 42 participants in a study said they
  or someone that they knew had experienced a
  medical error.
• Out of all healthcare professionals, RNs have
  been responsible for the most medical error
  related patient deaths.
• Due to nurses spending the most time with
  patients
• Anoosheh, M., Ahmadi, F., Faghihzadeh, S.,
  Vaismoradi, M. (2008). Causes and management of
  nursing practice errors a questionnaire survey
  of hospital nurses in Iran. International Nursing
  Review, 55(3), 288-295.
• Reinburg, Steven. (2009, April 27). Medication
  errors could be cut experts. US News and World
  Report. Retrieved from http//www.usnews.com/heal
  th/managing-your-healthcare/healthcare/articles/20
  09/04/27/medication-errors-could-be-cut-experts.ht
  ml

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Ways to Prevent Nursing Errors

• Ask another RN to double check your medication
  calculations
• Call physicians for order clarifications
• Double check pharmacy
• Only do what you can handle
• Ask questions when necessary, use available
  references
• Ask for clarification with orders that are not
  legible

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Ways to Prevent Nursing Errors (Cont.d)

• Use five rights of medication administration
• Right patient
• Right medication
• Right dose
• Right time
• Right route
• Austin, S. (2008). Seven legal tips for safe
  nursing practice. Nursing 2008, 38(3), 34-39.

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Ways to Prevent Nursing Errors (Cont.d)

• When transferring care of patient or report
  patients condition use SBAR
• Situation
• Background
• Assessment
• Recommendation
• Austin, S. (2008). Seven legal tips for safe
  nursing practice. Nursing 2008, 38(3), 34-39.

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Nursing Process

• Most legal actions brought against nurses arise
  because a patient or a patient advocate claims
  that the nurse breached a standard of care and
  that the breach resulted in harm to the patient
  (Austin, S. 2008).
• Nursing assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
• Austin, S. (2008 March). Seven legal tips for
  safe nursing practice. Nursing 2008, 38(3),
  34-39.

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Conclusion

• Nursing errors can be prevented, which is why we
  chose this topic to present to you today
• Just one error could lead to permanent loss of a
  nursing license making all the late nighters,
  stress, and four years or more of nursing school
  completely pointless

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References

• Anoosheh, M., Ahmadi, F., Faghihzadeh, S.,
  Vaismoradi, M. (2008). Causes and management of
  nursing practice errors a questionnaire survey
  of hospital nurses in Iran. International Nursing
  Review, 55(3), 288-295.
• Austin, S. (2008). Seven legal tips for safe
  nursing practice. Nursing 2008, 38(3), 34-39.
• Bohomol, E., Ramos, L., D'Innocenzo, M. (2009).
  Medication errors in an intensive care unit.
  Journal of Advanced Nursing, 65(6), 1259-1267.

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References (cont.d)

• Karlsen, K., Hendrix, T., O'Malley, M. (2009).
  Medical error reporting in America a
• changing landscape. Quality Management in
  Health Care, 18(1), 59-70.
• Ohio Board of Nursing (n.d.). Chapter 4723-4
  standards of practice relative to registered
  nurse or licensed practical nurse. Retrieved from
  http//codes.ohio.gov/oac/4723-4.
• Reinburg, Steven. (2009, April 27). Medication
  errors could be cut experts. US News and World
• Report. Retrieved from http//www.usnews.com/
• health/managing-your healthcare/healthcare
• /articles/2009/04/27/medication-errors-could-be-c
  ut-experts.html.

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Jeoparady
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1.) What is a nursing error?
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2.) Give four examples of nursing errors.
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• 3.) Jessica has been an RN at a local hospital
  for 1 week and she takes on an assignment that is
  to much for her to handle. Who should she talk
  to about this?

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• 4.) What is the website that displays the names
  of the nurses whove lost his/her license or had
  the license suspended?

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• 5.) Name two ways to prevent a nursing error.

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• 6.) Why are RNs considered the most responsible
  out of all healthcare professionals for medical
  error related deaths?

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• 7.) How does a nursing error affect a patient?

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• 8.) Are RNs required by Ohio law to document a
  nursing error?

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• 9.) Describe a situation where a nurse would be
  at risk for making an error.

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• 10.) Name three ways a nurse can do a nursing
  error involving medication administration.

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• 11.) Patients that are difficult are one of the
  causes of nursing errors.
• True or False

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• 12.) Are all nursing errors punishable?

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• 13.) Not listening to a patient does not mean you
  are committing an medical error. After all,
  nurses are busy and dont always have time to
  listen to every complaint.
• True or False

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• 14.) What is the nursing process?

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• 15.) What is two disciplinary actions that could
  result from a nursing error?

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• 16.) What does SBAR stand for?

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• 17.) Why is SBAR important?

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• 18.) What is the most common medical error?

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• 19.) You should not admit to a patient when you
  make a mistake. If you do, they may lose trust
  in you.
• True or False

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• 20.) If a nurse forgets to document a blood
  pressure from the 1100 vital check, it is okay
  because vitals are checked again at 300 so its
  just one time that day you forgot.
• True or False

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• 21.) How much are medication errors costing the
  healthcare system annually?

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• 22.) Name the five rights of medication
  administration.

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• 23.) Most legal actions brought against a nurse
  arise due to medication errors.
• True or False

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• 24.) When is SBAR used?

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• 25.) If a nurse receives an order from a doctor
  and doesnt understand one or two words, should
  the nurse still do what she does understand of
  the order?

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• 26.) Why should nurses report an error?

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• 27.) How do you report an error that you witness?

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• 28.) A nursing error can cause patient death or
  absolutely nothing.
• True or False

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• 29.) Why is it important to prevent a nursing
  error?