Factors influencing perioperative nurses' error reporting preferences

AORN Journal, March, 2007 by Sherry Espin, Glenn Regehr, Wendy Levinson, G. Ross Baker, Christina Biancucci, Lorelei Lingard

As concern over the number of health care errors has risen, so has interest in the development of care delivery processes that minimize the potential for error. Included among the strategies emphasized by the Institute of Medicine is a recommendation for developing reporting mechanisms by which system problems can be identified and corrected. (1) The success of reporting systems depends on the individuals charged with using them, however, and research has raised doubts about health care providers' willingness to take on this key reporting role. For example, Uribe et al (2) and Jeffe et al (3) identified barriers to reporting for both physician and nurse groups.

These barriers included

* fear of reprisal,

* lack of confidentiality,

* constraints on time, and

* lack of post-reporting feedback.

In their survey research, Taylor et al (4) found that one-third of nurses and physicians shared uncertainty about what is considered a medical error and identified similar concerns about implicating others to be a contributing factor in the underreporting of errors.

Despite these common barriers, research has shown that physicians and nurses have different approaches to reporting errors, reflecting their different professional cultures and values. (2) Kingston et al, (5) for example, found that nurses reported more habitually than physicians, and the researchers attributed this difference to nurses' cultural emphasis on directives, protocols, and the notion of security. Consistent with this attribute, the study by Jeffe et al, (3) which used focus groups of physicians and nurses, found that nurses were more knowledgeable than physicians about how to report errors. Lawton and Parker (6) also found that protocols influence nurses' reporting behaviors.

Although valuable, this previous research has focused on professionals' approaches to reporting errors that occur in the context of their own individual professional practice. (2-7) As a consequence, we do not know whether these reporting tendencies and attitudes apply in team settings where responsibility for an error may reside with professionals in other disciplines or may be shared by several team members. Many inpatient errors occur in team settings such as the intensive care unit or OR, so it is important to understand how professionals collaborating on interdisciplinary teams perceive and respond to error reporting in their everyday, multi-professional practice. It has been suggested, for example, that nurses collectively will be perceived as bearing the burden of responsibility for reporting errors in the team context, (5,8) but it is not known what conditions determine whether and how nurses would enact this perceived responsibility on behalf of the team. Would a perioperative nurse report the anesthesiologist's administration of penicillin to a patient who is allergic to this medication, and would reporting be affected by whether the patient experienced a severe reaction? Would a nurse report a burned common bile duct (CBD), and would this be affected by whether the burn necessitated conversion to an open procedure?

In a previous study, we began the process of characterizing nurses' error reporting preferences using scenarios from the perioperative team setting, such as a retained sponge after abdominal surgery. (9) In that interview study of nine nurses and 11 patients, nurses opted for reporting only 50% of events that they identified as errors. In contrast, the patients interviewed in the same study advocated reporting 93% of the events they perceived as errors. Nurses' dominant rationale for selective reporting was the perceived boundaries set by scope of practice. In situations where the error fell within the nursing domain, nurses asserted the need for consistent reporting. If, however, the error was perceived as peripheral to their scope of practice or central to that of other team members, nurses were unlikely to consider reporting to be appropriate or necessary.

When nurses did report an error outside their scope of practice, they most often justified their reporting in terms of the patient's negative outcome. (9) This second finding is consistent with that of Lawton and Parker, (6) who also found, in some circumstances, that an error that results in patient harm was more likely to be reported to a senior staff member.

The scenarios used in that study, however, were not specifically designed to evoke or explicate these two sets of rationales. Thus, although the data suggested that nurses are unlikely to report all events they perceive as errors, further investigation is required to determine how these two factors influence nurses' reporting preferences.

To this end, we used a grounded theory approach to explore further how the notions of Scope of practice and negative outcomes influence nurses' decisions of whether to report errors. Our purpose was to explore the role of scope of practice and seriousness of outcome in perioperative nurses' error reporting preferences. Using a set of scenarios that varied more broadly and systematically in terms of scope of practice (ie, within or outside of nurses' responsibility) and outcome to the patient (ie, presence or absence of a negative outcome), we asked the following questions.