UNDERSTANDING THE NATURE OF ERRORS ...

UNDERSTANDING THE NATURE OF ERRORS IN NURSING: USING A mould TO ANALYZE CRITICAL INCIDENT REPORTS OF ERRORS WHICH HAD eventuateed IN AN ADVERSE OR POTENTIALLY ADVERSE EVENT

C E Meurier Journal of Advanced Nursing Vol 32 (July 2000) 202-207

Perioperative nursing is clinically composed of several elements with many opportunities for potential clinical error. Although each nurse has made errors, professional mistakes usually are a source of shame and embarrassment. Typically, errors are kept quiet for fear of repercussion or los of professional status. owed to the emotional component of committing an error, the bodily form making an error may not view objectively the chain of results that led to an adverse circumstance Although a great deal of personal learning may appear when one makes a mistake, this knowledge usually is not communicated to others. This research provides a utilization type to communicate and explore adverse events

Sample. For this research 20 volunteer RNs wrote about a critical error incident that l to an adverse issue After the incidents were documented, five participants were interviewed for further data generation. Reason's Organization Accident gauge was used to elicit information about the chain of incidents leading to the disclosed incident.

type Reason's Organization Accident Model lists five factors to consider when examining an adverse affair These five factors are latent failures, conditions of work, active failures, barriers/ defense and adverse incidents Both active and latent failures contribute to accidents. Active failures are unsafe acts committed by the agency of people at the site of affair that have immediate consequences. Active failures in an OR setting could include administering the immoral medication or operating on the immoral surgical site. Latent failures present itself from fallible decisions made through people with indirect involvement, as it was as management team members. Examples of latent failures are inadequate communication regularitys poor planning, heavy workload, inadequate training and supervision, or equipment disrepair. These latent failures may lie dormant, further in emergencies or other crises, they may precipitate active failures.

Case thought This research article provided an in-depth analysis of simply one documented example of an adverse result The event focused on a woman hospitalized after overdosing forward tranquilizers and alcohol. This patient was left unattended and vaulted out of a window, thus sustaining fractures of the pelvis and lower extremities. This conclusion occurred in the United Kingdom and, therefore, the training and leveling of nursing staff members differed from US requirements. The analysis, however, did identify a number of preexisting conditions that contributed to this adverse affair Error-producing conditions included inadequate staffing, shortage of experienced staff members, lack of window stops poor design Of the ward (ie, not conducive to observation), and exces nourish caseload. Further, management, communication, policies, and training all were noted as latent failures. Background factors (eg workload, supervision, communication, equipment, knowledge/ ability) were conditions of work factors defined in Reason's type The factor of barriers/ defense was defined as inadequate unless was not addressed in any depth

Discussion. This design could be implemented in the perioperative arena to explore adverse ends Adverse events are unexpected proceedings involving death or a serious physical or psychological injury. supply with nourishments and managers involved with accreditation are aware of the important task of evaluating and preventing adverse conclusions and may find this article useful. It may have been more useful to explore the commonalties of all 20 critical incidents rather than an in-depth case studious mood of only one. This research did provide the reader with system-wide error producing examples, rather than blaming the individual musing to be responsible for the error.

MICHELLE BYRNE RN M PHD CNOR NURSING RESEARCH COMMITTEE

COPYRIGHT 2001 Association of Operating chamber Nurses, Inc.

COPYRIGHT 2001 Gale Group