Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

SafetyNurse1968, ADN, BSN, MSN, PhD

Mistakes Were Made

Is it possible to get through an entire nursing career without making a mistake? If nurses are well-trained and careful, can we prevent patient harm? What does it take to get through a hectic nursing shift without making an error? These are the questions that motivate me as an educator and a nurse researcher.

I wrote an article a while back talking about how nurses, despite our best efforts, make mistakes that sometimes lead to patient harm (Why Do We Continue to Harm Patients?) At the end of the article I gave a survey asking how many of my readers had made errors. Of the 39 folks who voted, 54% of you said you had never made an error. Compare that to the 18% who weren’t sure.

I’m going to make an argument that more mistakes and errors occur than you think by asking another question, how do we know an error has been made? The most common way healthcare organizations track error is through self-report, which is voluntary. We have to know we’ve made a mistake, be willing to report it, know how to report it, have time to report it and feel safe enough to report it before anyone finds out we’ve made an error. That’s a lot to ask for nurses who are often overworked, underpaid and who have zero job security. The evidence suggests we make many more errors than are reported. In one study, over a four-day period, pharmacists, RNs, LPNs and pharmacy technicians directly observed 2556 doses of medication administration in 36 hospitals across the US. They observed 300 errors (11.7%). An in-depth chart review over that same four-day period detected 17 errors (0.7%). And incident reports? You guessed it - there was 1 – giving an error rate of 0.4%.1In another study clinical evidence from 6 different direct observation studies was reviewed, and the differences were even more startling: “true” error detected by direct observation was 65.6%. Chart review yielded an error rate of 3.7%. Self-report gave an error rate of 0.2%.2

Fundamentals

I recently taught fundamentals of nursing to some brand-new BSN students. They had to do a simulated medication pass, and I used a checklist to grade them. It looked something like this:

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My students struggled with performing the three checks each and every time. (I added that they also needed to check the expiration date, something else they couldn’t seem to remember). I know nerves get in the way, and I was supportive and gave cues when needed, because at their level, cues are needed. We only expect a student nurse who is about to graduate to be able to do a med pass correctly, perfectly, every single time.

What inspired me to write this article was the experience my newbies had at the clinical site. After 10 weeks in the sim-lab, struggling to learn the basics of nursing care, things like bed making, bed baths, head to toe assessment, medication administration, they finally got to go to an actual facility and observe RNs, LPNs, and CNAs do the real job of direct patient care. They were incredibly nervous about talking to a patient for the first time, so worried they would make a mistake, say the wrong thing, mess up.At the end of the first day, we met for post-conference and some faces were shining with joy, I kid you not, at the realization that I can do this!There were also some hushed conversations about the reality of nursing. See if any of these quotes look or feel familiar:

“She didn’t tell the patient what any of the meds were for.”

“None of them do the three checks.”

“My nurse didn’t even check the patient’s arm-band.”

“She gave the wrong dose of insulin, and she realized it afterwards, but I never saw her tell the patient or fill out an error report. I could tell she felt really embarrassed.”

What Are We Teaching Kids These Days?

Do you remember in nursing school when they taught us about medication administration?

Here’s a list of what we are supposed to know about each and every medication (and I am sure I have missed a few):

Generic vs. trade
Classifications
Forms
Pharmacokinetics
Therapeutic vs. side effects
Allergies
Interactions
Timing (peak, trough)
Common schedules (AC, STAT)
Route
Method of measurement
Interdisciplinary (pharmacy, prescriber)
Types of orders (standing, PRN)
Distribution systems

Back in 2004, when I was a student, they were still doing five rights: dose, patient, drug, time and route. I did a little research and discovered that the five rights were first seen in The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities,1893.3 Since then, the number of rights has increased, one school even has 12! Some of those additional rights include things like documentation, client education, response, right to refuse. Do you remember how we were taught to check all the rights three times? The three checks: Check 1: when medications are pulled from where they are stored (med drawer, dispensing machine/Pyxis); Check 2: when preparing the medications for administration; Check 3: at the patient’s bedside.

I have three problems with this whole set up: 1) there’s no evidence to support this methodology; 2) it places all of the responsibility for patient safety on the nurse; 3) it only works if you do it, and we aren’t doing it. Our responsibility is to administer medication as prescribed while preventing error and patient harm(that’s straight from a Fundamentals texbook4) yet the error rate hasn’t changed.5

We are the last line of defense – physicians and advanced care practitioners prescribe medications, pharmacists fill the prescription, and the nurse gives the medication. As we go through our daily routine of checking and re-checking, nurses prevent up to 70% of prescribing and dispensing errors before they reach the patient.6 We prevent error by intervening when we see a medication order that doesn’t make sense, or identifying an allergy that was missed, or investigating with the patient and family to discover a previous medication issue not found upon initial assessment. Despite our best efforts, nurses may commit between 26% and 38% of medication errors.6In a 2010 survey, 78% nurses admitted to making a medication error, and these are just the ones they were aware of.7

The Fallacy Of The Careless Nurse

Some folks who read an article highlighting the nurses’ role in patient harm get angry, and I don’t blame them. Nurses are often vilified for errors that reach the patient. Nurses are at the sharp end of the stick – we are the last stop for safety. When things go wrong, we are often blamed. Yes, there are instances of bad nurses who do bad things. There are incompetent and careless nurses. There are nurses who don’t care. But I believe they are few and far between. What I am suggesting, is that it isn’t always our fault. I’m suggesting that healthcare systems are error-prone places. I’m suggesting that no matter what we do, errors will occur. Healthcare is just too complex. The odds are stacked against us. Statistics show that more than one error occurs per patient per hospital day.8I don’t believe there are that many careless nurses out there. I believe the system is deeply flawed. The culture of nursing is such that many of us are unwilling to even consider that we have made an error. And as you can see, we continue to teach our nursing students that just being carefulwill somehow magically protect them from making a mistake.

What To Do?

Nurses appear to believe that they should be capable of administering medications without errors, regardless of the external circumstances. When you ask nurses about error, we typically believe it’s all our fault. In 2003, 779 nurses were polled, and 79% agreed that medication errors occur when a nurse carelessly neglects to follow the 5 rights. 958% believed that the commission of a medication error was indicative of nursing incompetence. In 2008 the same poll was conducted, and those numbers have only increased.10This study highlights that negative opinions and individual blame continue to be associated with error making.

In the article I wrote about the role of nurses in error, I asked you for solutions and here is a list of your answers:

Staffing (over 50% of those who commented on my article suggested that staffing is at the root of the role nurses play in medication error.)
Incentives and benefits for senior, experienced nurses to stay at the bedside
Barcode medication administration
Electronic charting
Improving critical thinking
Prioritizing patient needs
Nurses are understaffed and overworked, caring for sicker patients in greater amounts with less support, experience and training
Total overhaul of BSN programs
Keep your head down, keep quiet and stay employed

Personal Safety Checklist

I agree with your ideas, but I’m not sure how to get them implemented, other than to tell you to go work at a magnet hospital in a state with safe staffing laws. I’m working very hard on improving critical thinking in my nursing students, but from the perspective of a BSN instructor, I can tell you a total overhaul isn’t on the horizon. I want you to know there are a few things we can do to safeguard our patients and our license. As a Certified Patient Safety Professional, a long-time nurse educator, a nurse who practices at the bedside, and former patient safety officer, I recommend nurses use the following checklist for personal safety measures. Anything you can complete from the following list has evidence behind it to support improved patient safety. As nurses, keeping patients free from harm is our goal, so why not pick one and get it checked off?

Education: BSN, MSN (patients cared for by nurses with higher degrees have better outcomes)
Nurse led research (nurses at the bedside are the best folks to initiate research that will make a difference in patient safety)
Certification (patients cared for by certified nurses have better outcomes)
Self-care (nurses who are stressed out and fatigued are more likely to make an error)
Ongoing training – look for the following components in your continuing education:
High quality CE (The ANA has some great free CE, and so do I!)
Simulation (So many studies show a positive relationship between high-fidelity simulation and improved patient outcomes)
Patient safety focus
Charting (Chart everything. Chart everything. Chart everything – for your safety as well as your patients’).
Use of checklists whenever possible (research shows use of checklists reduces error)

Speak up! Join the ANA and contribute to the Political Action Coalition today! If every nurse gave $1, we would have $3 million dollars to fund lobbying efforts to get safe staffing laws passed in all states. If we do nothing, nothing will change.11

End Note

Here’s one final item I have removed from the checklist because it isn’t a goal, though it is most likely a certainty in your life. The odds that a nurse will make it through a career without making a mistake are close to zero.

Previous involvement in error (nurses who have made errors that they recognize and take responsibility for are less likely to make them in the future)

I wrote a story about a wonderful, well-trained, careful nurse who made a mistake that harmed a p.html), and I encourage to you read it. It inspired me and I hope it inspires you as well. We must admit to and report error. If we don’t, we can’t know what problems need to be fixed. For more information on how organizations can improve, please read: This Nurse Quit, Will You? What to look for in an organization.