Strategies to move past that inevitable first error
New registered nurses confront a constantly changing and often chaotic practice environment. It may take several years for a new nurse to fully acclimate to the professional role. During that time, new nurses are more apt to make medical errors due to lack of experience, inadequate critical reasoning skills, and visual and auditory distractions.1,2
Research has shown that a single patient can receive as many as 20 medications in a day.3 Most nurses will make an error at some point during their career. Making an error may be personally devastating and embarrassing, but recovery is possible. If you make an error, you are not alone. And, you can learn from the experience.
Types of Medical Errors
The U.S. Department of Health and Human Services4 reports that 44,000 to 98,000 deaths may occur annually due to errors in hospitals. The National Council of State Boards of Nursing (NCSBN)5 has found that new RNs make more errors and report more negative safety practices than experienced RNs.
While medication errors still rank as the highest cause of medical error, The Joint Commission in 2013 6 reported that alarm fatigue is now a top safety concern and can result in injury and death to patients. A medical error is a preventable adverse care event that can result in patient harm or death. Errors can be made with medications, alarms, treatments, patient information, monitoring, documentation, and failing to follow policy.
Failing to follow a standard policy (e.g., call light cord within patient reach) may result in a patient fall. Forgetting to unclamp an IV may lead to a fluid deficit. Failing to check a new order for accuracy might result in the wrong dose being given to the patient. Errors also occur when organization policy and procedures are not followed or when nurses are fatigued, distracted or rushed. The first step in error prevention and recovery is an acknowledgement of the error. The second step is learning from the error to prevent it from occurring again. Being able to move forward is a final step in the right direction.
Discovery of Error
Errors can be discovered by nurses, physicians, pharmacists, other healthcare professionals (e.g., physical therapists, etc.) nonlicensed personnel, and even the patient or family. Someone else may discover the error, or the new nurse may self-report it.
When any error is discovered, the priority must be the patient’s safety. The patient must be assessed for any change of status. A physician must be notified, to allow the opportunity to order medication or treatment that might counteract the error. Because the effects of an error may not be immediately apparent, it is essential to disclose during shift report that an error was made. The error must be documented per the organization’s policy.
The Incident Report
If an error is made, an incident, event or occurrence report must be completed. Many organizations have developed nonpunitive or just culture policies, an approach that works to identify mistakes, improve safety measures and prevent repeated errors.7.8 Nonpunitive or just culture policies also recognize that multiple reasons may cause an error. It could even be a process failure rather than an individual mistake.
Depending on the organization, the document may be completed on paper or online. The incident report is a legal document and provides a written and verifiable record of the occurrence. This allows parties to analyze how the error happened, and to prevent repeated errors.9,10 Incident reports are routed to the unit manager and risk management team.
Incident reports should be completed thoroughly, beginning with date and time of event, patient information, and a description of the event itself. Include all people involved in the incident, what actually happened, and what you believe led to the error. Document the corrective action taken, and any people whom you notified. Sign the report and send it to the required departments. Avoid assigning blame, and do not speculate about what occurred.
While an incident report is a legal document, it is generally not placed or referenced in a patient’s health record. The incident report may be used if a lawsuit is filed. Filling out your first incident report may provoke feelings of anxiety, fear and failure, but keep in mind that this process will help you and others to start determining how the event happened and what can be done to prevent it from happening in the future.
Consequences of an Error
The consequence of an error is often dependent on its severity and the patient’s response. If the error caused a negative patient outcome such as temporary or permanent damage or death, the organization or patient may file a lawsuit. One way to prepare for a lawsuit is to retain legal counsel. Completing the appropriate follow-up steps after an error protects the nurse and the organization because it shows that steps were taken to correct the error.
State boards of nursing (SBNs) require that nurses report any discipline during initial licensure and at renewal. Because healthcare organizations counsel an employee after an error, such counsels might fall within the auspices of discipline as defined by an individual SBN. Being upfront on the licensure application or renewal is enough to satisfy an SBN. SBNs provide an area to write, in detail, about the error itself. SBNs want to know if a particular incident was isolated or if errors occur frequently with a particular nurse.
Surviving the Error and Moving On
Making an error may be traumatic and unexpected, but you can benefit from acknowledging and reporting it. If you make a medication error, return to the basics of the six rights of medication administration: the right drug, dose, route, time, patient and documentation. If the patient tells you it is the wrong medication or treatment, stop and check the order. Check physician orders for changes, and if you are unsure of a dosage, ask another nurse or the pharmacist to double-check your calculations. Double check to makes sure equipment alarms are set appropriately. Follow the organization’s policy and procedures. Listen to your intuition: If you think something is not right, double-check it.
Moving forward after an error can be difficult, but not impossible. It can be especially difficult if harm has come to a patient. Report any incident immediately, complete the required documentation, and be as honest and forthcoming as possible. Having someone to support you is necessary. Seek out help from your employer’s assistance program. Talk to a clergy member or confide in a close friend who will be supportive. Learn from the mistake, even if you are terminated. Learn to recognize distractions and avoid or minimize them when possible. Know and understand your organization’s policies and procedures.
New registered nurses are more vulnerable to making errors than more experienced nurses. You can recover, learn from the experience, and move on in your professional practice.
- Thomas CM, et al. Creating a distraction simulation for safe medication administration. Clin Simul Nurs.2014;10(8):406-411.
- Treiber LA, Jones J. H. Medication errors, routines, and differences between perioperative and non-perioperative nurses. AORN. 2012;96(3):285-294.
- Fontan J, et al. Medication errors in hospitals: Computerized unit drug dispensing systems versus ward stock distribution system. Pharm World Sci. 2003;25(3):112-117.
- U.S. Department of Health. Strategies to reduce medication errors: Working to improve medication safety. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm
- National Council of State Boards of Nursing. Transition to practice. https://www.ncsbn.org/transition-to-practice.htm
- The Joint Commission. Sentinel Event Alert Issue 50: medical device alarm safety in hospitals. http://www.jointcommission.org/assets/1/18/sea_50_alarms_4_5_13_final1.pdf
- Tocco S, Blum A. Just culture promotes a partnership for patient safety. Amer Nurse Today. 2013;8(5).
- Institute Of Medicine. To Err is Human: Building a safer health system. Washington D.C.: National Academies Press; 1999.
- Inglesby T. Incident reporting systems. Adverse events: Reporting and prevention. Patient Safety & Quality Healthcare. http://psqh.com/september-october-2014/incident-reporting-systems-reporting-and-prevention
- Mahajan RP. Critical incident reporting and learning. Brit J Anesth. 2010;105(1):69-75.