Objective: The first step in reducing threats to the safety of patients and nurses must be to determine the actual incidence of these threats. Hospitals rely primarily on voluntary reports of adverse occurrences, but we know that these are grossly under-reported. This makes it difficult to design safety promotion programs that address the real problem and makes it nearly impossible to determine the impact of these programs. The objectives of this research project were (1) to estimate the proportion of medication administration errors and patient falls that are reported, (2) to estimate the rate of occupational injuries and the proportion of these that are reported, and (3) to examine factors surrounding the occurrence and reporting of safety threats.
Design: A correlational study was conducted using a survey questionnaire sent to staff nurses.
Population, Sample, Setting: The population was staff nurses working on adult units in community hospitals in the US. As part of a larger study of nurse staffing and the quality of care, 50 hospitals were selected using a two-stage random sampling procedure and 85% of the study hospitals choose to participate in the optional nurse survey.
Concepts, Variables: This report addresses six variables: reporting medication administration errors, reporting patient falls, reasons for not reporting medication errors, occurrence of occupational injuries, reporting of occupational injuries, and reasons that adverse occurrences happen.
Methods: To date, 3590 questionnaires were sent to 18 hospitals for distribution to staff nurses. The number of staff nurses who received questionnaires is not known. Responses were coded only for units and questionnaires were returned directly to the researchers. This report includes responses from 732 nurses working on 106 units.
Findings: Nurse respondents averaged 40 years of age and 13 years of experience and were 6.6% male and 70% Caucasian. Reporting rates for medication administration errors ranged between 38% for oral/topical medications and 48% for intravenous medication. Patient falls were reported at a higher rate - 71% for falls with no injury and 78% for falls with major injury. Two sets of reasons for not reporting were scored about equally (1-5 scale) - fear of repercussions 3.44 and inappropriate administrative response 3.23. Nurses indicating low medication error reporting scored higher on the reasons for not reporting (r=-.180 fear and -.211 admin response).
Nurse respondents reported occupational injuries from the last three months and whether they had reported that injury. For back injuries, 126 (18%) had experienced this injury but only 18 (14%) reported it; 40 had experienced a needlestick and 21 (52%) reported the occurrence; and 169 (34%) had been exposed to body fluids but only 16 (10%) reported this occurrence.
The questionnaire contained lists of reasons for adverse occurrences. Respondents choose the three most important reasons from each list. For medication administration errors, the top three reasons were distractions and interruptions (52%), RN to patient ratio (38%), and wrong medication delivered (31%). For patient falls, the top three reasons were patient cognitive condition (66%), patient physical condition (50%), and RN to patient ratio (38%). Exposures to blood borne pathogens were attributed to chaotic conditions on the unit (46%), stress and crisis on the unit (40%), and not following standard precautions (36%). For back injuries, respondents choose not enough people to help move patients (70%), obese patients unable to assist in movement (54%), and increasing numbers of total care patients (47%).
Conclusions: Respondents indicated that less than 50% of medication administration errors were reported. Patient falls were more likely to be reported; but, surprisingly, only 78% of falls with major injuries were reported. The nurse respondents indicated that both fear of repercussions and inappropriate administrative response were reasons for not reporting medication administration errors. Low levels of reporting were also apparent in occupational injuries, from a low of 10% of exposures to body fluids and a high of 52% of needlesticks. The respondents identified reasons for adverse occurrences, many of which are related to low staffing levels and stress, crisis and chaos on patient care units.
Implications: The results of this survey underscore the need to encourage reporting of safety threats such as adverse occurrences. Reducing the fear of repercussions and appropriate responses to reports of errors may boost reporting rates. In addition, nurses respondents identified conditions on the unit and other system problems related to adverse occurrences. These conditions can be addressed to promote safety. Finally, the information about the rate of voluntary reporting provides a baseline from which to judge the impact of safety initiatives.
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