Monitoring and measuring errors and adverse events across the surgical continuum - Research Corner

AORN Journal,  March, 2002  by Suzanne C. Beyea

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Monitoring and measuring errors in health care present any challenges. Traditionally, many clinicians have hesitated to report errors for fear of punishment or sanction. Some health care workers may avoid reporting errors made by other clinicians out of concern that filing a report would get someone in "trouble." Although clinicians always have been concerned about safety, it has not been clear how reporting errors could lead to clinical improvements or error reduction.

MONITORING SYSTEMS

Many health care facilities have implemented some type of variance or occurrence reporting system in an effort to track adverse events or unusual occurrences. Rarely do systems such as these track "near misses" or minor errors that do not result in patient injury. Regardless of the type of monitoring system, the value of consistently reporting and recording all types of errors or near misses has not been made clear to clinicians or administrators. Even when data are collected, they are not used consistently or systematically to examine factors that contribute to errors.

In many hospitals, for example, incident reports related to medication errors are placed in a clinician's personnel file to track his or her personal error rate. No one systematically examines and analyzes these reports to identify trends. To understand errors of any type, trends and factors that contribute to errors must be identified. In the case of medication errors, it would be helpful to know whether they occur on a specific clinical unit or shift or at a specific service or time of day. Also, it would be helpful to know whether similarities exist among errors related to the providers who wrote medication orders, the pharmacists who dispensed medications, the patients' acuity, or the types of medications. Monitoring and recording this type of data would provide helpful information that could be used to minimize subsequent errors. Currently, this information is not readily available, and if it has been collected, it may not be reliable, valid, or amenable to interpretation.

WHAT IS AN ERROR?

In most health care facilities, health care providers lack a common vocabulary and approach to understanding and describing errors, near misses, and adverse events. Multiple inconsistencies exist in the way errors are interpreted and how data about them are collected, recorded, and analyzed.

In the case of medication errors, consider late medications. Is administering medications late considered an error? Many health care facilities have policies that allow medications to be administered 30 minutes before or after the scheduled dose; however, few error reports are submitted when medications are administered 40 or 50 minutes late. Perhaps on some clinical units there are a few diligent nurses who complete a report each time a medication is administered later than policy stipulates. In fact, many times medications are administered later than ordered due to the timing of food trays or diagnostic and laboratory tests; however, the clinician administering the medication late may not consider this an error. Other clinicians question whether a daily medication scheduled at 9 AM is ever late as long as it is administered during the day shift.

Reliable and valid data related to the time medications are administered and consistent reporting of late medications would provide information that could lead to clinical improvements. Perhaps medications are administered late because the pharmacy fails to deliver medications in a prompt manner or staffing is inadequate to administer medications in a timely fashion. These are flawed systems that can lead to individual clinicians making errors. If the flaw is identified, subsequent errors can be prevented by making appropriate changes in the system.

Error reports can be inconsistent when clinicians interpret the meaning of late in different ways. Furthermore, late administration of daily medications may have different implications for time-sensitive medications. For example, the timing of administering antibiotics to preoperative patients is critical to minimize the risk of postoperative infection. Should a preoperative antibiotic that is administered late be considered an error when other similar errors are dismissed as usual and customary practice? Obviously, adverse events such as an infection can be costly to both the patient and health care system; therefore, it is important to document and analyze these data in a consistent manner.

WHY MEASURE?

In most clinical environments, reliable and valid data about errors, near misses, and adverse events simply do not exist. When data do exist, they may not be comparable across settings and may be erroneous. In the current health care system, there have been no requirements for reporting or recording information about near misses or adverse events. Many perioperative nurses, however, can recall an incident of wrong site surgery, retained instruments, unintentional ligation of the ureter, unintentional nicking of an artery or organ, or some other misadventure during surgery. Other than being recorded as part of the patient record, these data are not available or accessible for analysis.