Nurses Want a Greater Role in Error Disclosure
By Susan Kreimer, MS, contributor
Nurses often feel left out of physicians’ talks with patients about medical mistakes. Welcoming nurses into error disclosure discussions should be a top priority, a new study reports.
“It’s not a matter of intentionally excluding nurses as much as not being aware that they need to be intentionally included,” said the study’s lead author, Sarah E. Shannon, RN, Ph.D., vice associate dean for academic services at the University of Washington School of Nursing in Seattle. With health care delivery spanning various shifts, “it could be just a logistical issue of getting people together.”
The study, which surveyed 96 registered nurses in a total of 11 focus groups, was published in the January 2009 issue of The Joint Commission Journal on Quality and Patient Safety. It noted that leaving out nurses from disclosure planning sessions can create complications later when patients or their families ask questions. The exclusion also may contribute to moral distress, less job satisfaction and higher turnover among nurses.
Divulging errors should entail a team effort, the authors said. This means sharing information with one another about what occurred and why, and discussing what is being done to mitigate potential harm and prevent future mistakes. For consistency, everyone also needs to know what the patient has been told, will be told, and when.
The authors recommend that hospitals model their error disclosure policies after the ones developed for ethics consultations. Such policies foster a collaborative approach and help protect employees against retribution for voicing their input.
“They create a safe harbor for anyone on the team, regardless of their power, to be able to raise questions or concerns about a case,” Shannon said. While nurses are more likely to talk with patients about errors within their control, they seem reticent to mention mistakes made by others.
Simulation training would help physician leaders and nurse managers to coach others in effective error disclosure. The training could involve working with professional actors representing the interdisciplinary teams in health care.
“We know that we should be disclosing errors,” Shannon said. “But as with many communication skills, people are more likely to receive a lecture on it than to actually have the opportunity to practice.”
Minor lapses, such as giving medication two hours late and not causing harm, are relatively easy to disclose. Serious errors leading to death or organ malfunction pose greater challenges.
The authors noted that communication breakdowns led nurses to describe the error disclosure process as “walking on eggshells.” In one instance, a “nurse discovered that the wrong patient had been taken for a procedure involving barium. She quickly called the lab and stopped the procedure. However, when the patient returned to the floor she resorted to silence.”
The unidentified nurse is quoted as saying she felt “awkward and uncomfortable” and wasn’t sure if she should apologize or pretend that the doctors had decided against performing the procedure.
Error disclosure is advocated by the American Medical Association, the American Nursing Association and the Joint Commission on the Accreditation of Healthcare Organizations. The codes of ethics for all health care professionals and entities also support disclosure of harmful errors.
In addition, “it’s very clear from research that patients want to be told of errors that occur in their care,” Shannon said. “There’s a very strong endorsement for transparency.”
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