Nurses Hesitate to Report Errors
By Debra Wood, RN, contributor
Nurses know the value of reporting errors but feel conflicted about disclosing a mistake, according to a recent study in the Journal of Patient Safety.
“Error communication is important but doesn’t happen frequently enough for a variety of reasons, such as time, nurses thinking it was not serious enough to report and not knowing what happens to the reports after they are made,” said Suzanne Brungs, RN, MSN, MBA, coauthor of the study and a health system specialist with the VA Healthcare System of Ohio.
Brungs and colleagues conducted eight focus groups attended by 33 intensive care unit nurses from four hospitals and randomly surveyed 92 nurses from the same units, asking all participants about their medical error decision-making.
Nurses in the focus groups indicated time pressures as a factor in not reporting, along with whether or not the patient was harmed. They also said they received little feedback when they did formally disclose a mistake, which reinforced the perception that reporting is not meaningful. Focus group nurses characterized the error reports as “falling into a black hole.”
In contrast, nurses who took the survey said they usually or always reported errors and received feedback, a more socially desirable response. However, 22 percent of the respondents had not submitted a report in the past year.
Other studies have found that errors in the ICU occur at a rate of greater than one per patient day, leading the investigators to conclude that the survey responses were close to the focus group findings.
“In an age of transparency, we must be honest,” Brungs said. “You cannot fix things unless you know the problem.”
As a nurse manager, Brungs said she wanted to know what errors occurred on her unit, so she could evaluate the processes and prevent mistakes from happening in the future. Yet despite promoting a culture of reporting, she found it difficult to get nurses to speak up.
“Things might appear to be working well, when really they are not,” Brungs said.
The researchers found that nurses perceive errors as a result of failure of skill, motivation or knowledge. Brungs said one nurse told the focus group if she reported an error her name would be mud, so she doesn’t do it.
“Nurses blame themselves or anther person,” Brungs said. “There is a stigma.”
Brian Lokar, RN, a staff nurse in the emergency department at the University of California, San Diego Medical Center-Hillcrest and an adjunct clinical instructor at Southwestern College, was not surprised by the research findings. He said nurses fear they will loose their jobs and that reporting often varies depending on how trusting nurses are of others on the team.
“Camaraderie has a lot to do with it,” Lokar said. “It’s hard because you are admitting failure. You are expected to work flawlessly in a very busy environment.”
Lokar agreed with the study respondents that staff nurses rarely hear about the outcome of reported mistakes, unless they attend management meetings. More communication about changes made in response to errors or near misses could help.
The study also found that if the nurse picks up on a problem created by a physician, nurses will likely not confront the doctor. Brungs said nurses often play a game to try to get physicians to recognize their own mistakes, so the nurse does not have to call it to the doctor’s attention.
“This has been going on since the beginning of time,” Brungs said.
Although such behavior has a long history, the authors said that this authority gradient or power distance has been found to be a significant factor in errors and harm.
“Mistakes happen, but many hospitals are taking steps to prevent them by not punishing people for honest errors but still holding people accountable for reckless behavior,” said Lillee Smith Gelinas, RN, BSN, MSN, FAAN, vice president and chief nursing officer at VHA Inc., a national health care alliance that helps hospitals with performance improvement.
Gelinas said hospitals need to develop a culture of patient safety, looking at total system issues to quantify the risks and then put plans, education and practices in place to counter those risks. She encourages creating a “Just Culture,” one that is fair and allows nurses to learn from mistakes. Chief executive officers from across the VHA network have come together to learn about just culture and how to implement it at their facilities.
With just culture, “you find nurses speak up more and feel more open,” said Gelinas, who predicts hospitals will need to adapt such an approach to retain staff. “The more we implement just cultures, the more nurses will benefit and feel like they are not on the sharp edge of getting fired if they say anything. They will have the opposite view that if they speak up, they are honoring the portion of their license that says we are patient advocates.”
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