Patient safety experts at Johns Hopkins have calculated that more than 250,000 deaths per year in the United States are caused by medical errors (McMains, 2016). In 2013, the Centers for Disease Control and Prevention (CDC) ranked the top three causes of death as heart disease, cancer, and respiratory disease. In 2016, researchers at Johns Hopkins found that medical errors replaced respiratory disease as the third leading cause of death (Makary & Daniels, 2016; McMains, 2016). In international comparisons of deaths that are considered preventable by timely and effective healthcare, data showed that the United States had the highest number of preventable deaths in comparison to nine other countries, with France and Australia being the lowest (Nolte & McKee, 2011). How can nurses help to address this problem by shaping a culture of safety in healthcare? Keep reading for some helpful, safety-promoting suggestions.
Students in the Advanced Clinical Nursing class that I taught were assigned to write a paradigm case--a story that reflected an ethical dilemma that they had experienced in their clinical practice. It was made clear that they needed to write something they could share with others, as we would set aside class time to read their stories aloud. With 22 students gathered in a circle in the classroom, Sarah* prefaced the reading of her story by confiding that she had read it to her husband before class. He asked her whether she really thought she should share the story openly. She replied, “Yes.”
“Do no harm.” This ethical principle has guided my nursing practice for almost 30 years. As a young nurse I was taught the 5 rights of medication administration. As an oncology nurse, I am painfully aware that many of the chemotherapy agents that I administer have the potential to cause death if not administered properly. Some time has passed now since I made a mistake that could have easily cost my patient her life. Today I share my story to help us think about what we can do to reduce the possibility of errors in our practice.
The day that Mrs. May* received more than twice the dose of chemotherapy that had been ordered for her was not just any day. It was very close to Christmas. I was feeling especially excited because after being a registered nurse for over 25 years, I had finally completed my Bachelors of Science in Nursing. I was proud of my accomplishment and had received many compliments and best wishes for continued professional success.
Mrs. May had been a patient in our practice for more than a year following a diagnosis of cancer, but I had not met her. I introduced myself and administered the chemotherapy. Afterward, Mrs. May went directly to see her physician and her chart went with her, so I did not have a chance to record the medications that I had given. At the close of the day, I realized that I had never charted on Mrs. May’s record, so I retrieved her chart. As I looked at the dose of medication the oncologist had written, I felt a lump forming in my throat. I knew for a fact that I had mixed and administered two and a half times that amount. The medication was new to me. I remembered reconstituting 4 vials. I knew that I had given 250 mg instead of the 100 mg. that had been ordered.
My heart began to race. I went back through the chart and realized that the dilution of the drug had been written where I had become accustomed to seeing the dose of the drug. Since the drug was under the same classification as another that I administered regularly, I didn’t question that this might be too high a dose. Immediately, I went to the nurse manager to tell her what had happened. I knew that if Mrs. May died, there was a good chance that I would not ever be allowed to practice nursing again. Instead of giving me a reprimand, my manager said, “Let’s make sure that you truly gave that much of the drug. You are always so careful.” Together we went through the trash and found the 4 boxes. My heart sank. I kept thinking, “This lady is going to die and it is right at Christmas time.”
Today, I still remember the kindness that was bestowed on me that day. When I told the oncologist about my terrible error, he stated that he had ordered a lower dose of the medication for Mrs. May than normal for a patient with her condition, as she had a life expectancy of only 6 months to a year and didn’t want to live with serious side effects from the chemotherapy. The oncologist said that she would be very, very sick for about a month but would not die from the overdose. He would treat her aggressively with agents to increase her cell counts so that she would have enough reserve to keep her counts from going down to zero.
The next morning Mrs. May came to the clinic. I arrived early to tell her how very sorry I was. She said that her oncologist had told her if I had not come forth and told him of the mistake, she might not have lived. She trusted the doctor that she would not die from the error.
I am happy to say that Mrs. May is still alive today. She certainly was a very sick lady for the next 2 weeks. One day she said to me, “I will not lie to you. I have never felt this bad in my life, but I will make it.” Yes, Mrs. May made it. Her tumor decreased to one half its original size in about a month. Almost 2 years after this incident, Mr. and Mrs. May were able to enjoy an international vacation together. I talk with Mrs. May whenever she comes to the clinic and she always gives me a hug and reassurance that she is okay.
Was I unbelievably fortunate? Yes. Can a medication error happen to even the most careful and conscientious nurse? Yes. Am I even more conscious of my ethical obligations to provide safe care? Yes. This incident has changed my life. I share my story with other nurses with the hope that it will cause them to think, “If it could happen to her, it could happen to me.”
Sarah read this story** to my class a number of years ago but I still remember vividly how I felt after she finished. The classroom was totally silent. Many of us were fighting back tears. A classmate reached over to put her arm around Sarah’s shoulder, a silent acknowledgement of support and admiration for the courage that Sarah had shown in sharing such a personal story. I think probably everyone in that room still remembers the moment when we each realized, “It could happen to me.”
Medical errors are not typically caused by a negligent or incompetent healthcare professional. Instead they are often the result of a breakdown in processes that guide delivery of patient care (Bonney, 2014). Sarah was a competent, careful, and caring nurse, but variances in the usual process of care set up a situation for error. The medication was new to Sarah and was ordered in a format that led to confusion of dose versus dilution. Medication orders should be written in clear and consistent formats so that the person administering the drug can readily understand the appropriate dose. Also, the chart was removed from the clinic setting before Sarah had a chance to record the medication administration. Access to the order on the medical record while administering the medication provides an important safety check to ensure the correct dose is both administered and recorded.
Many potential and actual medical errors fall within the sphere of nursing practice (Lachman, 2007). Thus nurses have an ethical obligation to help prevent and manage medical errors. The remainder of this column will discuss ethical principles related to medical errors for nurses to consider, along with recommendations that can help to shape a culture of safety for the prevention of medical errors.
Ethical issues related to medical errors can be categorized around four ethical principles: autonomy and right to self-determination; beneficence and nonmaleficence; disclosure and right to knowledge; and veracity (Bonney, 2014). Each of these principles will be discussed below.
Autonomy and Right to Self Determination
Concepts of autonomy and right to self determination acknowledge patients’ rights to make their own choices and to take actions based on their personal views and perceived benefits. Healthcare providers have an ethical obligation to inform patients about their ongoing plan of care, including if a medical error has occurred. If Sarah had not informed others of her error, Mrs. May would not have been able to make appropriate decisions about the treatment that she needed as a result of the error. Healthcare providers are also obligated to assist patients in making decisions, as the physician did in his care of Mrs. May. The physician’s honest discussion with Mrs. May about the medication error and potential adverse effects helped her to maintain trust in those caring for her and follow their instructions for treatment so that she could minimize harm from the error.
Beneficence and Nonmaleficence
The principles of beneficence and nonmaleficence direct healthcare providers to do what is best for patients and avoid harm. This may create moral conflicts for healthcare providers in terms of balancing projected benefits with possible risk for the patient. Although there is a range of severity in errors, they all cause harm – to the patient, to the person who made the error, and/or to the system (Kalra, Kalra, & Baniak, 2013).Healthcare providers should take necessary steps to minimize the harm caused by an error. Sarah may have thought that informing Mrs. May of the error would cause unnecessary worry and suffering but had she not informed others of her error, Mrs. May would not have received important treatments to offset potential harm.
Disclosure and Right to Knowledge
Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making. The patient’s bill of rights calls for full disclosure of a medical error (Ghazal, Saleem, & Ariani, 2014). Fortunately, in Sarah’s situation healthcare providers disclosed the information needed to help Mrs. May make decisions about her care, thus respecting her autonomy and decreasing the potential for harm. Every institution needs clear and detailed policies for disclosure of information about medical errors.
The principle of veracity requires healthcare personnel to provide comprehensive, accurate, and objective information in a manner that helps patients understand the information. Telling the truth about medical errors helps to establish trust. Healthcare providers’ careful communication with Mrs. May helped to establish a sense of trust that can be seen in the mutual respect that Sarah and Mrs. May shared years after the unfortunate incident.
Medical Errors: Telling Your Story
Communication researchers suggest that the ways healthcare providers 'story' their mistake experiences can help to understand medical errors (Noland & Carmack, 2015).
Storytelling shifts thinking from ‘rational and scientific’ patterns to reflective thought that calls forth a detailed context surrounding the experience. Sarah’s story illustrates the importance of context as she remembers why she did not record the medication she had administered to Mrs. May. She remembers the lump forming in her throat when she realized her error, her fear of losing her nursing license, her gratitude for the kindness of her nurse manager and the physician, and the trust that Mrs. May had in her healthcare providers, even after the error. Reflective thinking helps to uncover beliefs, values, and knowledge embedded in the experience (Noland & Carmack, 2015). Storying an experience of a medical error helps the narrator and ‘listeners’ to come to know, understand, and make sense of the experience.
The prevention of medical errors within an organization requires systematic management strategies. Healthcare providers need education to understand the importance of reporting medical errors. Researchers in a study of 289 Canadian nurses working in long-term care noted that participants had different definitions of what constitutes harm with a medical error; their perceptions of harm influenced whether they reported the error (Wagner, Damianakis, Pho, & Tourangeau, 2013). Because of busy working conditions, these nurses prioritized which errors to report. One participant stated, “If it’s caused no harm, it’s no big deal!” (p.3). Participants indicated overwhelmingly that they would like to receive continuing education to help them learn how to handle the 'after effects' of error occurrence. Nurses in all settings need education and training to develop a shared definition of harm and understand the process for reporting errors.
Although fear of litigation is often cited as a barrier to disclosure by healthcare providers, there is no established link between willingness to disclose medical errors and the risk of litigation (Bonney, 2014). Sarah’s story revealed multiple factors that contributed to her error, such as a new medication and a system event that delayed recording the medication. The culture of the organization, however, supported 'reporting' of her error. A 'blame culture' is a major source of medical errors (Kalra et al., 2013). Organizations must create an environment where healthcare providers feel supported in reporting, disclosing, and discussing errors.
Considerable research in recent years has focused on disclosure of medical errors but has lacked interdisciplinary dialogue (Hannawa, Beckman, Mazor, Paul, & Ramsey, 2013). Research is needed that incorporates disciplinary perspectives of professionals in healthcare, law, communication, and ethics to help healthcare providers understand and implement ethical practices for prevention and management of medical errors.
The American Nurses Association (ANA) defines a Culture of Safety as a work culture in which healthcare providers at all levels of the organization are committed to core values and behaviors that emphasize safety over competing goals (ANA, 2016). Literature related to medical errors suggests that most medical errors are preventable (Bonney, 2014). The categories listed in the Box below reflect important ways that nurses can contribute to prevention and management of medical errors (Noland & Carmack, 2015; Zikhani, 2016). As the largest group of healthcare professionals, over 3 million strong, registered nurses are in a unique position to lead initiatives that promote a culture of safety (ANA, 2016).
Box. Strategies for Prevention and Management of Medical Errors
Rules and Policies. Involve nurses in the development of clear and detailed policies for creating a safer environment in their organization.
Communication. Convey messages promptly and clearly. Handoff tools, such as SBAR or task debriefing, are effective ways to reduce communication failures.
Checklists, Reminders, and Double Checks. Design checklists and similar tools to reduce medical errors, especially in situations where errors tend to occur.
Simplification, Standardization, and Organization. Break down and standardize procedures and organize care-implementation processes into simple steps.
Computerization and Automation. Identify best practices for using technologies, such as healthcare informatics, to promote efficiency and accuracy and avoid errors.
Forcing Function. Devise procedures that make it almost impossible for errors to occur. For example, prevent an individual from entering a wrong medication into the computer or starting a process without submitting a completed checklist.
Sharing Stories of Errors. Encourage students and practitioners to tell their stories of medical errors, rather than hiding errors out of fear, and to listen to stories from others. Knowing how others have handled mistakes, or wish they had handled them, can help other staff prevent and/or manage healthcare errors.
*Sarah and Mrs. May are pseudonyms used to protect the privacy of individuals involved in this story.
**This story is adapted from the chapter, Do no harm, as reported in the book Defining moments: The courage to be [Chapbooks]. The book was part of a class project and self-published by Jeanne Sorrell. The copyright date for this book is May 2001 and the copyright is held by Jeanne Sorrell.
Jeanne Merkle Sorrell, PhD, RN, FAAN
Jeanne Sorrell is former Senior Nurse Scientist, Nursing Research and Innovation, at the Cleveland Clinic in Cleveland, OH, and Professor Emerita, George Mason University in Fairfax, VA. She earned a BSN from the University of Michigan in Ann Arbor, MI, a MSN from the University of Wisconsin in Madison, WI, and a PhD from George Mason University. Her scholarly interests focus on philosophical inquiry, writing across the curriculum, qualitative research, and ethical considerations in healthcare.
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