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

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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? This article attempts to answer these questions and more. I’ve included a personal safety checklist as well.

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

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.

REFERENCES

1.  Barker, K., Flynn, E., Pepper, G., Bates, D., & Mikeal, R. (2002). Medication errors observed in 36 healthcare facilities. Archives of Internal Medicine, 162(16), 1897-1903.

2. Kiekkas, P., Karga, M., Lemonidou, C., Aretha, D., & Karanikolas, M. (2011). Medication errors in critically ill adults: A review of direct observation evidence.(report). American Journal of Critical Care, 20(1), 36-44.  

3. Wall, B. (2001). Definite lines of influence: Catholic sisters and nurse training schools.Nursing Research, 50(5), 314-321.

4. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016).Fundamentals of nursing (9thed.). Philadelphia, PA: Elsevier.

5.  Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Phil, M., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124-2134.

6. Bates, D. W. (2007). Preventing medication errors: A summary. American Journal of Health-System Pharmacy, 64(14), S3-S9. doi:10.2146/ajhp070190

7. Jones, J. H., & Treiber, L. (2010). When the 5 rights go wrong: Medication errors from the nursing perspective. Journal of Nursing Care Quality, 25(3), 240-247. 

8. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication      error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41.  

9. Cohen, H., Robinson, E. S., & Mandrack, M. (2003). Getting to the root of medication errors.      Nursing, 33(9), 36-46.

10.  Cohen, H., & Shastay, A. D. (2008). Getting to the root of medication errors: survey report.         Nursing, 38(12), 39-47.

11.  https://www.nursingworld.org/practice-policy/advocacy/

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Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes at the word processor. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

26 Likes, 6 Followers, 28 Articles, 10,833 Visitors, and 163 Posts.

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Hmmm. 1 ER I worked was gigged by JCAHO because we didn't document enough med errors the previous year. Apparently they have a sliding scale for med errors based on annual census! How do we win?

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Ooof, a nurse who claims to never have made an error or mistake makes me really worried because they're either not aware of their errors or they're hiding them. No way have 54% of nurses never made an error. 

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I still think the medication administration process your school is teaching is a crime.

This is a process involving basic but critical steps that must happen every single time. It should not be complicated with anything else.

The *very* first thing that will need to happen in order for these students to function as new RNs is that they will need to omit parts of the process they were taught. Hopefully they know to drop the head-to-toe assessment part and not the "read the label" part.

Edited by JKL33

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In my opinion, one of the problems is that nursing education today consists of much less hands on practice at the bedside taking care of patients than in the past, and practicing skills in Sim lab for 10 weeks (as you mentioned in your article) and then going to the facility to "observe" staff providing care instead of actually providing hands on patient care under one's clinical instructor's supervision means that students are far less prepared to practice than in the past.  When I was a student we learned/performed the skills in the skills lab, were checked off for competency, and then performed the skills on patients we were assigned to in the hospital under our clinical instructor's supervision.

You seem to be contradicting yourself when on one hand you say that medication administration is far too complex for individual nurses to be held responsible for medication errors (when they administered the medication) the majority of the time, yet on the other hand you reference your students' training (10 weeks in Sim lab and then at the facility to "observe" the staff providing care) while stating that BSN trained nurses have been shown to have superior patient outcomes - what particular outcomes are you talking about?  Your comments lead me to presume you are not talking about safe medication administration outcomes. 

The five/six rights are not obsolete and are still referenced in nursing procedure books (I have a current edition of a reputable one) for medication administration.  The five rights work to prevent errors, and do prevent errors, but more knowledge of medications and of health care processes is necessary in order to administer medications safely.  Vigilance and critical thinking are necessary also; one cannot just go on autopilot.  You said the five rights only works when we do it.  Well, of course, and the recent thread about the Vecuronium error contains many references to safely administering medications and using the five rights; did you read that thread?  A number of nurses who posted on that thread made the point that the nurse is the last defense before a medication error reaches the patient, and therefore needs to have a personal practice with a robust method for preventing medication errors, including the five rights.  Nurses are held individually accountable for their practice by the state Boards of Nursing.   

 

Edited by Susie2310

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Considering nurses are human...well most of them, haha...it isn't possible to be perfect/never make a mistake. Also, as long as there is some element of discipline that can be attached/associated with reporting an error there will be a reluctance to report. So, if an error isn't reported there isn't the possibility to problem solve and have an opportunity for future prevention...hence the cycle continues. I have made errors during my nursing career and have reported NONE of them for this very reason.

Most Nurses, nowadays, are required to complete a probationary period upon employment wherein they display their competency to independently complete the required nursing tasks. If they don't prove their competency they should be discharged from the position. If they do prove their competency and the employer proclaims they have successfully completed their probationary period they employer should understand, AND EXPECT AND PREPARE, that person will make a nursing error and encourage and reassure the nurse the reason for reporting an error is to prevent future occurrences and will not be considered a cause for discipline/not to build a discipline file to use against the employee in the future. Of course, I'm not talking about some heinous, premeditated, act or so act of conscious negligence.

Same attitude should be taken by the state BONs.

Just my 2 cents to throw in...good article SafetyNurse...thank you.

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I taught ADN students as a Clinical Instructor for a semester both in the skills lab and in their first Med/Surg Unit clinical rotation. Personally, I think the way nursing school teaches concepts seem disjointed and promotes more of a task-oriented yet less critical thinking approach. Medication administration is part of the patient's medical management. An understanding of the medications themselves, why they were ordered for the patient, and basic understanding of dosing and side effects are more important than following rote tasks to the point of doing unnecessary full head to toe assessment that do nothing but delay the process and sidetracks the nurse's thought process.

A family member was in an ED and was subsequently admitted to a Tele Unit. As the family member present at the bedside, I have detected quite a few things that should not have happened and fortunately pointed it out to the nurses who were there to provide care. Examples such as double doing on anticoagulation medications, delay for hours of rate controlling medications for an arrhythmia, etc were all possibly attributable to being overworked but I was also careful not to embarrass or make the nurses involved feel intimidated.

It is important to possess skills of triaging and critical thinking in our heads what each of our patient's medical problems were, what the required treatments to improve their medical condition through medications were, and how time can be managed to get each patients to the point of getting better through these medications. The whole thing must be a seamless orchestration of providers knowing how to correctly write the orders, pharmacy being the check and balance, clear medication labelling and visual cues, and a workflow that allows for uninterrupted medication administration and access to medication supplies in a timely manner.

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3 hours ago, OldDude said:

Considering nurses are human...well most of them, haha...it isn't possible to be perfect/never make a mistake. Also, as long as there is some element of discipline that can be attached/associated with reporting an error there will be a reluctance to report. So, if an error isn't reported there isn't the possibility to problem solve and have an opportunity for future prevention...hence the cycle continues. I have made errors during my nursing career and have reported NONE of them for this very reason.

Most Nurses, nowadays, are required to complete a probationary period upon employment wherein they display their competency to independently complete the required nursing tasks. If they don't prove their competency they should be discharged from the position. If they do prove their competency and the employer proclaims they have successfully completed their probationary period they employer should understand, AND EXPECT AND PREPARE, that person will make a nursing error and encourage and reassure the nurse the reason for reporting an error is to prevent future occurrences and will not be considered a cause for discipline/not to build a discipline file to use against the employee in the future. Of course, I'm not talking about some heinous, premeditated, act or so act of conscious negligence.

Same attitude should be taken by the state BONs.

Just my 2 cents to throw in...good article SafetyNurse...thank you.

This approach protects the nurses at the expense of the public who are entrusting their care to qualified, competent nursing professionals.  You have described a "no employment consequences or civil consequences approach" for errors in care that may harm or actually do harm or kill patients, which many health care professionals would naturally like.  The general public places a huge amount of trust in the medical and nursing profession.

I am very aware that nurses often don't report their errors in medication administration (or other mistakes), just as some nurses sign the medical record with their first names only, which is why as a nurse I stay by my family members' bedside 24/7 when they are hospitalized - I don't have fundamental confidence in the nurses' honesty, competence, and professionalism (which has been borne out in my experience), and if I am proved wrong I am happily surprised.  A basic competency assessment when a nurse is first hired is no predictor of how they will continue to perform their job.  The general public, who are the recipient of nursing care, deserve accountability for medical/nursing errors.  The public has the right to receive competent, safe care by the nursing/medical professionals they are placing their trust in, and they are entitled to a full investigation in situations where they fail to receive this.

 

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I just posted the reply below to OldDude's comment, and for some reason it is not showing up unless I am logged in, hence my posting my comment again:

This approach protects the nurses at the expense of the public who are entrusting their care to qualified, competent nursing professionals.  You have described a "no employment consequences or civil consequences approach" for errors in care that may harm or actually do harm or kill patients, which many health care professionals would naturally like.  The general public places a huge amount of trust in the medical and nursing profession.

I am very aware that nurses often don't report their errors in medication administration (or other mistakes), just as some nurses sign the medical record with their first names only, which is why as a nurse I stay by my family members' bedside 24/7 when they are hospitalized - I don't have fundamental confidence in the nurses' honesty, competence, and professionalism (which has been borne out in my experience), and if I am proved wrong I am happily surprised.  A basic competency assessment when a nurse is first hired is no predictor of how they will continue to perform their job.  The general public, who are the recipient of nursing care, deserve accountability for medical/nursing errors.  The public has the right to receive competent, safe care by the nursing/medical professionals they are placing their trust in, and they are entitled to a full investigation in situations where they fail to receive this.

 

Edited by Susie2310

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Sometimes I feel like the persons who write these "checklists" never have actually worked on a floor. What is the rationale behind a head to toe prior to giving medication? I can't imagine having to head to toe my patients any time I give them their medications. Or taking their vitals that many times, unless the particular med I am calling for needs current vitals and they hadn't already been taken in the past 15 minutes. It's bad enough that when I started my patients' all looked at me as if I were stupid and like I was an idiot every time I went to give them meds and I was asking them "name and date of birth" for the 6th time.. 😕 

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21 hours ago, SafetyNurse1968 said:

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

What gets me is the expectations that nurses should know all this before administering a medication.  Some of this list is common to nursing practice, some not so much. For instance I honestly have no clue what peak/trough are of every med I administer and in my opinion I shouldn't need to. While we are the "last line of defense" in preventing errors that doesn't mean we should be held responsible for knowing our job, the pharmacist's job and the provider's job.  Nor should nurses be held accountable when the error originates from the pharmacy or provider.  They  have many more years of education in their field than the nurses that are blamed when  the cause of an error originates from a mistake a pharmacist or a provider made.

Edited by kbrn2002

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