Human Error and Healthcare Incident Reporting among Nurses: Do We Need to Rethink our Approach?

Purpose:

For over a decade the healthcare industry has attempted to mimic the non-medical industry with the use of incident reporting as one of many learning tools used to increase safety worldwide. WHO suggests, “Reducing medical errors has become an international concern” (World Health Organization, 2005). But it is difficult to have effective safety cultures if nurses, the largest contributor of adverse event reporting, have to overcome difficult barriers when reporting a mishap. Globally, nursing research literature from Taiwan, Greece, Australia, and Great Britain have explained that barriers nurses have had to overcome in order to report an adverse event include fear of reprimand, self-preservation, and peer confidence, to name a few. Chiang, Lin, Hsu and Ma (2010) noted that nurses appear to view incident reporting as a mark of a personal failing instead of a natural course of systemic contribution of a variety of processes. And as a healthcare system, this view may be resonated. For example, nurses are often at the sharp-end of a long string of providers and processes for medication administration however, they are often the focus of reprimand after an adverse event and can be reported to their peer review boards. Secondly, healthcare workers are trained to focus on perfecting their individual performance and the incident reports are frequently focused on character flaws. These barriers could also be influenced by nursing state laws, as well as healthcare organizational statements offering a broad range of approaches to errors made. Like many organizations, nursing organizational documents offer diversity in portraying newer collaborative systemic approaches to error as well as hanging on to some older concepts of complete individual responsibility. And state laws tend to count minor errors which can increase fear of reporting thus decreasing chances for learning from errors. This variety of wide-ranging standards can lead to little reporting and less learning from mishaps. Using a safety science framework, Old View vs. New View approach, this research study examined how the healthcare systems’ approach to human error can influence the nurses’ perception of human error as it is demonstrated in the incident reporting culture.

 Methods:

A qualitative exploratory case study approach was used to interview registered nurses and nurse managers to explore their depth of knowledge of human error as it relates to incident reporting.  Document analysis of related healthcare organizational documents and state nursing laws were analyzed for the relationship to errors made and incidents reported. The semi-structured interviews were at a major research academic hospital that employs over 10,000 and includes more than 40 hospital care areas. Three nurse managers’ and five inpatient nurses were interviewed to understand nurse’s experiences, values, and opinions related to human error and incident reporting. As  Blaxter, Hughes and Tight (2010) suggests, some advantages of a case study are that it draws on people’s experiences and practices, allowing the researcher to show the complexity of social life. The interviews were used to explore nurses and nurse manager’s knowledge of human error as it relates to writing or not writing of incident reports. A questionnaire was created involving five questions on human error and five questions regarding incident reporting. Healthcare organization documents and state laws were analyzed to examine healthcare system’s views of human error, incident reporting and their possible influence on the perception of human error and compared to the responses gathered from the interviews.

 Results:

Significant findings resulted in nurse’s perception of human error as character flaws more than a normal component within a complex system. Characteristics defined by nurse participants that human error was noted to be -a lack of competency, lack of education or judgments were recurrent themes. Nurse’s perception of their own organization’s handling of human error focused most on the severity of the event, scape-goating and getting rid of the bad apple.  Nurses appeared to utilize the incident reporting tool for tattling, severity bias; and self-preservation. Document analysis of Texas nursing laws, ANA Code of Ethics, and Position Statements of Just Culture,and AHRQ-Incident Reporting vacillated between promoting or limiting incident reporting.

 Conclusion:

Results from the study can be used to discuss and identify how nursing organizations and state laws promote or stifle reporting of errors made by nurses. A safety culture, as safety science has suggested, continues to promote the more proactive approach to errors made and a systemic resolve. Awareness of understanding the human fallibility within healthcare’s complex system is more conducive to learning how humans interact within the system rather than a focus on individuals and the understanding that our ethos is not related to accidents. Since nurses are the most frequent user of incident reporting, an evaluation of how it is being used is highly suggested.  More research is needed to determine whether nurses believe their ethos is related to errors made.