Download The ethics and practical importance of defining

ARTICLE IN PRESS
International Journal of Nursing Studies 43 (2006) 367–376
www.elsevier.com/locate/ijnurstu
The ethics and practical importance of defining, distinguishing
and disclosing nursing errors: A discussion paper
Megan-Jane Johnstone, Olga Kanitsaki
Division of Nursing and Midwifery, School of Health Sciences, RMIT University, Plenty Road, Bundoora Vic 3083, Australia
Received 16 November 2004; received in revised form 20 April 2005; accepted 26 April 2005
Abstract
Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international
literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of ‘nursing
error’, the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct
definition of ‘nursing error’ fits with the new ‘system approach’ to human-error management in health care are
critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are
advanced to support the view that although it is ‘right’ for nurses to report nursing errors, it will be very difficult for
them to do so unless a non-punitive approach to nursing-error management is adopted.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: Nursing errors; Patient safety; Ethics; Incident reporting; Clinical risk management
What this paper adds to the literature
Individual nurses who make honest mistakes continue
to be treated in a punitive way and are often ‘named,
blamed and shamed’ for their mistakes, despite calls
being made internationally for a non-punitive approach
to human-error management in health care domains.
What is already known about the topic?
Nursing
errors (e.g. medication errors) are an
acknowledged and ever-present problem in health
care domains.
Nursing errors, like other errors, tend to be underreported—even by nurses who are acknowledged as
the ‘majority reporters’ of incidents.
Non-punitive, anonymous incident reporting is now
universally recognised as an important strategy in
improving incident reporting rates and helping to
reduce the risk and incidence of ‘honest errors’ in
nursing and health care domains (‘We can’t fix what
we don’t know about’).
What do we now know as a result of this study?
The
Corresponding author. Fax: +61 3 9467 1629.
E-mail addresses: [email protected]
(M.-J. Johnstone), [email protected] (O. Kanitsaki).
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2005.04.010
notion of ‘nursing error’ as such is poorly
defined in the nursing literature making its meaningful discussion problematic; this paper addresses
this oversight by offering a carefully considered
operational definition of ‘nursing error’.
There are important practical and moral reasons, not
previously discussed in the nursing and related
literature, for defining, distinguishing and disclosing
nursing errors even though this might seem at odds
with the new ‘system approach’ to human-error
management that is being advocated worldwide.
ARTICLE IN PRESS
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
368
As
disciplinary and legal cases in a range of
jurisdictions continue to demonstrate, reporting
nursing errors is not without significant risk to the
nurses involved.
Nursing errors will continue to be under-reported
and a ‘system approach’ to managing human error in
nursing care domains continually undermined unless
nurses are given complete immunity from disciplinary action and legal prosecution when making and
disclosing their ‘honest errors’.
1. Introduction
Since the early 1990s, research studies conducted,
respectively, in the USA, UK and Australia have found
that between 4% and 16.6% of patients suffer from
some kind of harm (including permanent disability and
death) as a result of adverse events while in hospital
(Brennan et al., 1991; Department of Health, 2000;
Kohn et al., 2000; Leape et al., 1991; Vincent, 2001;
Wilson et al., 1995). These studies have also found that a
significant percentage (around 50%) of the reported
harms that occurred could have been prevented—that is,
were ‘preventable adverse events’ (Kohn et al., 2000,
p. 28; Leape, 1994). Concerned by these figures and their
possible implications on health services outside the
jurisdictions in which the research studies were originally conducted, governments, health care services and
health professional groups around the world have
turned to giving unprecedented attention to the development and implementation of processes aimed at
reducing the incidence and impact of preventable
adverse events in health care and to improving generally
the safety and quality of their health care services
(Committee on Quality of Health Care in America,
2001; Kohn et al., 2000; WHO, 2001; World Health
Professions Alliance, 2002).
It is widely accepted that a critical first step in adverseevent prevention in health care domains is to identify the
problem. This is because, as Bagian et al. (2001) have
famously argued, ‘You can’t fix what you don’t know
about’. The process most commonly used in hospital
practice to identify problems is incident reporting.
Reporting incidents, however, is not without risks—
particularly where the incidents reported involve adverse
events resulting from preventable practice errors and
mistakes (Johnstone and Kanitsaki, 2005; Johnstone,
2004a; Dickens, 2003; Hall, 2003; Anderson and
Webster, 2001; Bovbjerg et al., 2001; Liang, 2001; May
and Aulisio, 2001; Pinkus, 2001; Smetzer, 1998; Cohen,
1997). Nurses who make honest errors (to be distinguished from nurses who are reckless, incompetent,
impaired, uncaring, or who have malicious and/or
criminal intent) are particularly vulnerable in this
regard. As case studies to be presented later in this
paper will show, errant nurses can sometimes find
themselves the subjects of severe disciplinary action
and even criminal prosecution for their honest mistakes
and, related to these outcomes, burdened with what
May and Aulisio (2001, p. 142) describe as ‘the stigma of
implied ‘‘failure to care’’’.
In this paper, attention is given to examining
discourses surrounding nursing errors and the professional and ethical requirement of nurses to report
nursing errors. In advancing this discussion, brief
attention is first given to clarifying what constitutes a
‘nursing error’, the incidence and impact of nursing
errors and the problem of nursing errors being underreported. Attention is then given to advancing a
philosophic critique of why it is important to define
and distinguish nursing errors (i.e., as distinct from other
kinds of errors) in patient safety discourses, processes
contributing to the problem of nurses under-reporting
their errors (including the inherent risks to the nurses
themselves of making disclosures) and the apparent
contradiction in terms of distinguishing nursing errors in
the context of the ‘system approach’ to human-error
management that is being widely advocated in the
international patient safety literature and management
practices. Finally, consideration is given to the implications for nurse education, research and global practice
of taking a non-punitive approach to nursing-error
management. It is the ultimate conclusion of this paper
that if the new ‘system approach’ to human-error
management and patient safety that is being advocated
globally is to succeed, nurses must be given complete
immunity from disciplinary action and legal prosecution
when disclosing their honest mistakes.
2. What is a ‘nursing error’?
The word error originates from the Old French erren,
meaning to wander or to stray (from the from Latin
errāre) and is defined by the New Oxford Dictionary of
English (2001) as simply ‘a mistake’ and as ‘the state or
condition of being wrong in conduct or judgement’. For
the purposes of patient safety research, practice and
management, however, the following more sophisticated
definition (devised by Reason, 1990) has been adopted:
Error will be taken as a generic term to encompass all
those occasions in which a planned sequence of
mental or physical activities fails to achieve its
intended outcome, and when these failures cannot
be attributed to the intervention of some chance
agency (Reason, 1990, p. 9).
According to Reason (with reference to the work of
Rasmussen and Jensen, 1974), errors maybe classified
into three types: skill-based slips and lapses, rule-based
ARTICLE IN PRESS
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
mistakes and knowledge-based mistakes. Skill-based
slips and lapses are those ‘in which actions deviate from
current intention due to execution failures and/or
storage failures’ (Reason, 1990, p. 53). Such errors
commonly occur during the performance of ‘some
routine task, usually in familiar surroundings’ (Cho,
2001, p. 79) or when ‘skilled people perform many
tasks at once’ (Runciman and Moller, 2001, p. 14).
An example of a skill-based error is wrong drug
administration.
Rule-based and knowledge-based mistakes, in turn,
concern those in which ‘the actions may run according
to plan, but where the plan is inadequate to achieve the
desired outcome’ (Reason, 1990, p. 53). Rule-based
errors may arise in at least three forms: ‘the misapplication of a good rule (usually because of a failure to spot
the contraindication), the application of a bad rule, or
the non-application of a good rule’ (Reason, 2001,
p. 13). Reason (2001) explains that rule-based errors
‘relate to problems for which the person possesses some
pre-packaged solution, acquired as the result of training,
experience, or the availability of appropriate procedures’
(p. 12). An example of a rule-based error is a ‘routinely
inadequate checking process’—a process that can (and
does) lead to many incidents and accidents, such as
wrong patient/wrong site surgery.
Knowledge-based mistakes, in contrast, ‘occur in novel
situations where the solution to a problem has to be
worked out on the spot without the help of preprogrammed solutions’ (Reason, 2001, p. 13). A knowledge-based error may occur, for example, when ‘trying
to diagnose what has gone wrong with a malfunctioning
system’ (Reason, 2001, p. 13). Reason explains that in a
situation such as this, we are at risk of making mistakes
because of a tendency to:
‘‘pattern match’’ a possible cause to the available
signs and symptoms and then seek out only that
evidence that supports this particular hunch, ignoring
or rationalising away contradictory facts (Reason
2001, p. 13).
What then is a nursing error? For the purpose of this
discussion, a nursing error (as distinct from a medical
error, for example) is defined as a discipline-specific term
that encompasses an unintended ‘mishap’ (e.g. involving
slips, lapses, misjudgements, etc.) made by a nurse and
where a nurse (as opposed to some other health care
professional) is the one who is situated at the ‘sharp end’
of an event that adversely affected—or could have
adversely affected—a patient’s safety and quality care.
In short, a nursing error is that in which a nurse (as
opposed to a doctor or a pharmacist or someone else)
stands as being the last causally and critically linked
person to an unintended ‘effect’ (consequence or outcome). It is important to clarify at this point that it is not
369
inconsistent for more than one nurse, or for a nurse and
another health professional (e.g. a doctor), to both be
situated concurrently at the ‘sharp end’ and both being
causally and critically linked (like two handles on a vase)
to an unintended effect (consequence) to a patient.
Indeed, an error might consistently involve both a
nursing-identified and other-identified (e.g., medical)
error.
Significantly, it is only recently that attempts have
been made to define and formally classify nursing errors.
For instance, in a study examining 21 case studies of
nursing errors from nine State Boards of Nursing filed in
the USA, Benner et al. (2002) identified eight categories
of nursing errors representing what is described as a
‘broad range of possible errors and contributive or
causative factors’. Listed in Benner et al.’s taxonomy of
nursing errors are the following:
Lack of attentiveness (e.g., missed predictable complications, such as a postoperative haemorrhage)
of agency/fiduciary concern (e.g. failure to
advocate for the patient’s best interests/ failure to
question a doctor’s inappropriate directives)
Inappropriate judgement (e.g., failure to recognise the
implications of a patient’s signs and symptoms)
Medication error (e.g. wrong drug, wrong route,
wrong amount, etc.)
Lack of intervention on the patient’s behalf (e.g.,
failure to follow up on signs of hypovolemic shock)
Lack of prevention (e.g., failure to prevent threats to
patient safety such as via breaches of infection
control precautions)
Missed or mistaken doctor/health care provider’s
orders (e.g., carrying out inappropriate orders/
mistaking orders, resulting in an erroneous intervention)
Documentation errors (e.g., charting procedures or
medications before they were completed/ failure to
chart observations) (adapted from Benner et al.,
2002).
Lack
Unfortunately, it is beyond the scope of this present
paper to provide a critique of Benner et al.’s and other’s
(e.g., Berry, 2000) taxonomies of nursing errors. Nonetheless, it is evident that the taxonomies that have been
developed stand as an important starting point for what
is shaping up to be a rich and fertile area for future
international research and professional debate.
3. Incidence and impact of nursing errors
All nurses who have practised nursing have made a
mistake at some time during their career. Even so, there
are no precise figures on the incidence and impact of
ARTICLE IN PRESS
370
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
nursing errors in health care. Compounding the
difficulties associated with trying to estimate the
incidence and impact of nursing errors is the reality that:
not all practice errors result in adverse events and,
conversely, not all adverse events are the result of
practice errors (Leape, 1994); and
errors (and their ‘near misses’) tend to be underreported—even by nurses, who are widely acknowledged as a group that reports incidents more
significantly than do other health professionals,
including doctors (Kingston et al., 2004).
In regard to the latter, estimates vary on the degree to
which incidents (including errors and mishaps) are
under-reported, with some commentators suggesting
that under-reporting rates could be as high as 94% in
some areas (e.g., the reporting of adverse drug events),
with average reporting rates being between 15% and
48%—depending on the perceived seriousness of the
incident (Secker-Walker and Taylor-Adams, 2002,
p. 424; King, 2001; Antonow et al., 2000). Incidents
perceived as being ‘serious’, intentional and/or that have
had a bad outcome tend to be reported more frequently
than incidents that are perceived to be ‘not serious’,
unintentional and that have not had adverse outcomes
(Lawton and Parker, 2002; King, 2001; King and
Hermodson, 2000). Given the enormous variables that
exist in the field (Clark, 2004) and the acknowledged
underdevelopment of the epidemiology of ‘medical
mishaps’ (Mulcahy and Rosenthal, 1999, p. 14), it is
unlikely that a reliable estimation of the incidence and
impact of nursing errors in health care domains will be
obtained in the near future.
It is acknowledged that there exists some controversy
surrounding the reliability of the statistics of preventable
adverse events in hospitals and that caution should be
exercised when interpreting and applying them in patient
safety discourse (e.g. Clark, 2004; Hayward and Hofer,
2001; Lilford, 2002). Nonetheless, there is an emerging
consensus that the figures reported are a ‘very modest
estimate of the magnitude of the problem’ (Kohn et al.,
2000, p. 2) and are more likely to be a ‘gross
underestimation’ of the actual incidence of preventable
adverse events (Clark, 2004, p. 7). Whatever the figures,
as Kuhn and Youngberg (2002, p. 159) correctly point
out, ‘the actual number is less important than the fact
that anyone dies (or is harmed) needlessly from
preventable medical (and nursing) error’.
4. Human-error management
Human error in health care (as in all lines of work) is
inevitable. While it is impossible to eradicate human
error, it is nevertheless possible to design and put in
place systems (processes) that will help:
reduce the likelihood of error; and
reduce the negative impact of error
when it does
occur (Faugier et al., 1997; Kohn et al., 2000;
Reason, 2000; Vincent, 2001).
Kohn et al. (2000, p. ix) explain that ‘errors can be
prevented by designing systems that make it hard for
people to do the wrong thing and easy for people to do
the right thing’. For instance, just as cars are designed
‘so that drivers cannot start them while in reverse’ (i.e. to
prevent drivers from accidentally backing over people or
into things when starting their cars), so too can health
care systems be designed to ensure that ‘patients are safe
from accidental injury’ (Kohn et al., 2000, p. ix).
There is an emerging international consensus that
most human errors are largely the products or consequences of a series of events or ‘upstream’ system
processes, rather than of individuals ‘at the sharp end’
(the practice edge) doing the wrong things (Reason,
2000). Nevertheless, as Reason (2000) points out, there
has been a longstanding and widespread tradition (that
is still dominant in health care and elsewhere) of
naming, blaming and shaming individual people who
have been involved in unsafe acts. While blaming errant
persons (what Reason calls the ‘person approach’) might
be more satisfying than targeting institutions (‘If something goes wrong, it seems obvious that an individual (or
group of individuals) must have been responsible’), such
an approach stands to thwart the development of safer
health care institutions (Reason, 2000, p. 768). This is
because the ‘person approach’ overlooks two key
features:
Firstly, it is often the best people who make the worst
mistakes—error is not the monopoly of an unfortunate few. Secondly, far from being random, mishaps
tend to fall into recurrent patterns. The same set of
circumstances can provide similar errors, regardless
of the people involved (Reason, 2000, p. 769).
In contrast, a ‘system approach’ (which takes as its
basic premise that ‘humans are fallible and errors are to
be expected, even in the best organisations’) does not
seek to name, blame and shame. Rather it seeks to
‘discern and learn’ and to treat ‘‘‘every defect as a
treasure’’ because each one presents us with an
opportunity to improve’ (Walshe, 1999, p. 59). Reason’s
position on this point is unequivocal: ‘when an adverse
event occurs, the important issue is not who blundered,
but how and why the [system] defences failed’ (emphasis
added) (Reason, 2000, p. 768).
ARTICLE IN PRESS
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
things less patent and striking which would not have
happened in London civil hospitals nursed by
women. The medical officers should be absolved
from all blame in these accidents. How can a medical
officer mount guard all day and all night over a
patient (say) in delirium tremens? The fault lies in
there being no organised system of attendance. [y]
Were a trustworthy woman in charge of the ward, or
set of wards, the thing would not, in all certainty,
have happened (Nightingale, 1980 edn., p. 29).
5. Nursing-error management
The International Council of Nurses (ICN) holds that
‘patient safety is fundamental to quality health and
nursing care’ and that all nurses have a fundamental
responsibility to ‘address patient safety in all aspects of
care’, including (but not limited to) ‘informing patients
and others about risk and risk reduction’, ‘advocating
for patient safety’ and ‘reporting adverse events to an
appropriate authority promptly’ (ICN, 2002, p. 1). In
keeping with the principles of a ‘system approach’ to
human-error management, the ICN explains:
Early identification of risk is key to preventing
patient injuries, and depends on maintaining a
culture of trust, honesty, integrity, and open communication among patients and providers in the
health care system. ICN strongly supports a systemwide approach, based on a philosophy of transparency and reporting—not on blaming and shaming the
individual care provider—and incorporating measures that address human and system factors in
adverse events (ICN, 2002, p. 1)
The nursing profession has long been at the forefront
of the development and implementation of processes
aimed at preventing practice errors, injuries and threats
to patient safety. Indeed, although not widely recognised, Florence Nightingale was among the first of the
modern health professionals to advocate a system
approach to human-error management in hospitals. In
her classic book Notes on Nursing (first published in
1859 and still in print today), Nightingale laments the
‘fatal accidents’ she had observed directly or known of
and which, in her opinion, would not have happened
had there been in existence an ‘organised system of
attendance’ notably of qualified nurses. She writes:
If you look into the reports of trials or accidents, and
especially of suicides, or into the medical history of
fatal cases, it is almost incredible how often the whole
things turns upon something which has happened
because ‘he’, or still oftener ‘she’, ‘was not there’ [y].
The person in charge was quite right not to be ‘there’,
he was called away for quite sufficient reason, or he
was away for a daily recurring and unavoidable
cause: yet no provision was made to supply his
absence. The fault was not in his ‘being away’, but in
there being no management to supplement his ‘being
away’ (Nightingale, 1980 edn., pp. 28–29)
Notwithstanding Florence Nightingale’s insights and
innovations and the long history of the nursing
profession’s advocacy of patient safety, it has never
been easy for nurses to fulfill their many responsibilities
associated with preventing practice errors, injuries and
threats, to patient safety. As the nursing literature (too
numerous to list here) and the examples to be given later
in this paper amply demonstrate, fulfilling the responsibilities associated with upholding patient safety has
not been without significant moral and legal risk to
nurses, raising important questions concerning the ethics
of committing, communicating and correcting nursing
errors in practice domains.
6. The ethics and practical importance of reporting
nursing errors
When a mistake is made, admitting and promptly
reporting the error to an appropriate authority is the
‘right thing to do’. This is because hiding errors can have
serious adverse consequences at both a moral and a
practical level. At the moral level, hiding errors
(especially those that are clinically significant) may
result in:
otherwise avoidable harm to patients, i.e., on account
of:
depriving the relevant parties (doctors, nurses,
patients and their loved ones) of information that
is otherwise necessary to correct the error that has
been made, including the provision of effective
post-error care and treatment;
J depriving the patient (and his/her surrogates) of
their entitlement to make informed choices and to
provide informed consent to ongoing post-error
remedial cares and treatments;
J imposing on patients and their loved ones an
unjust burden of suffering on account of a hidden
error not being remedied;
the nurse–patient fiduciary/trust relationship being
seriously undermined and, ipso facto, the good
standing and reputation of the nursing profession
as a whole (notably on account of the agreed ethical
and professional practice standards of the profession
J
She goes on to state:
Upon my own experience I stand, and I solemnly
declare that I have seen or known of fatal accidents,
such as suicides in delirium tremens, bleeding to
death, dying patients being dragged out of bed by
drunken Medical Staff Corps men, and many other
371
ARTICLE IN PRESS
372
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
concerning patient safety reporting requirements)
being violated.
On a practical level, if errors are left unreported,
hospital incident data collected may be unreliable and
hence misleading, resulting in lost opportunities for
valuable ‘lessons to be learned’ from the mistakes that
were made. Without complete data sets, it will not be
possible to get a picture of the true nature and frequency
of a problem which, if left unchecked, may result in
future otherwise avoidable harmful errors occurring
(Secker-Walker and Taylor-Adams, 2002, p. 423; see
also Amoore and Ingram, 2002; Hart and Hazelgrove,
2001). As noted earlier (with reference to Reason, 2000),
if the same set of circumstances continues to exist, then
even if different people are involved, the same error will
occur.
7. The problem of under-reporting nursing errors
Earlier in this paper, it was acknowledged that
nursing and related errors tend to be under-reported.
A key reason for this concerns the ‘name, blame and
shame’ approach that continues to be predominant in
health care domains when dealing with incidents
(Webster and Anderson, 2002; Anderson and Webster,
2001; Mission, 2001; Cohen, 2000). Despite the substantial change in thinking that is occurring with regard
to practising error management in health care, those
who are the subject of a report are still likely to find
themselves ‘vulnerable to increased surveillance, complaints, negligence claims, disciplinary action and a loss
of respect among colleagues’ (Mulcahy and Rosenthal
1999, p. 12). In cases where a practice error has resulted
in a patient’s death, practitioners may also find
themselves the subjects of criminal prosecution for their
mistake (Cohen, 1997; Smetzer, 1998; Johnstone, 1994).
Those who report the errors of others might likewise find
themselves vulnerable to increased surveillance, complaints and a loss of respect among colleagues (Bolsin,
2003; Johnstone, 2004a, b). Employer organisations,
meanwhile, may find themselves being brought into
disrepute and their services shunned (even by people
needing emergency life-saving treatment) as a result of
adverse media publicity surrounding practice-error cases
(Johnstone, 2004a).
Nurses, like others, are often reluctant to report
practice errors because of their ‘fear of reprimand from
those in authority’ and a related ‘unwillingness to accept
responsibility for errors in which they may merely have
been a final player in a complex series of events’ (Walker
and Lowe, 1998, p. 97). The nurses’ fear in this instance
is not without basis. Indeed, the nursing profession has a
long and confronting history of its members being
named, blamed and shamed for practice errors, including those made by others, such as medical practitioners
and pharmacists. Reliable and convincing evidence of
this can be found in the various law reports on nursing
negligence cases that have occurred over the past 150
years in a range of common law jurisdictions, including
those found in the UK, USA, Canada, Australia and
New Zealand (see, in particular, Johnstone, 1994,
pp. 188–194).
A poignant example of nurses being unjustly named,
blamed and shamed for a practice error can be found in
a 1996 US case in what has become known colloquially
as the ‘Colorado Nurses’ Trial’. This case involved three
Colorado nurses who were indicted for a criminally
negligent homicide after mistakenly giving a 10 fold (and
lethal) overdose dose of the intramuscular medication
penicillin G benzathine intravenously to a neonate
(Smetzer, 1998). Following their indictment, two of the
nurses pleaded guilty in response to a plea bargain; the
third nurse, who refused the plea bargain, was acquitted
(Smetzer, 1998). Significantly, the indictment of all three
nurses was met with widespread criticism of the Colorado criminal justice system, with some accusing it of
taking ‘a giant step backward’ and undermining new
initiatives aimed at encouraging the active reporting of
errors and, ipso facto, improving the system (Cohen,
1997). Of particular interest to commentators, however,
was information that was provided for use at the trial
that enabled the relevant parties to identify ‘over 50
different failures in the system that allowed this error to
develop, remain undetected and ultimately, reach the
infant’ (emphasis added) (Smetzer, 1998, p. 49).
Commenting on the case, Smetzer (1998), a Fellow at
the Institute for Safe Medication Practice, reflects:
Had even one [of the major system failures] not
occurred, the chain of mistakes would have been
broken and the infant wouldn’t have been harmed
(p. 49).
Nurses in Australia have likewise experienced being
named, blamed and shamed for practice errors that, as
in the case of the Colorado nurses, were largely due to
major system failures, not their own. This is most
evident in what might be broadly referred to as the ‘fatal
intravenous KCl cases’ involving the mistaken administration of a fatal dose of concentrated potassium
chloride (KCl) intravenously to patients. Nurses involved in such cases have been severely disciplined for
failing to prevent the error from occurring. An
informative example of this can be found in a 1996
Australian case in which three nurses were reported to
the Nurses Board of Victoria for their involvement in
the administration of an incorrect intravenous dose of
potassium chloride that resulted in a patient’s death.
During the disciplinary hearing that followed, all three
ARTICLE IN PRESS
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
nurses were said to be experienced nurses ‘with very
good records who had never previously done anything
to warrant any disciplinary action’ and ‘had all been
seriously affected by the patient’s death, suffering
distress and loss of confidence’ (Nexus, 1996, p. 6).
The disciplinary panel hearing the case accepted that, on
the basis of evidence presented to it, the drug order was
confusing. The panel found, however, that the nurses
had nevertheless ‘failed to read the concentration and
dosage details on the label of the medication bottle’ and
that if they had found the order confusing ‘they should
have sought clarification’ from the prescribing doctor.
Accordingly, the panel found that all three nurses had
engaged in unprofessional conduct of a serious nature
and determined that each nurse have her/his registration
suspended (Nexus, 1996, p. 7).
Almost 8 years after this determination, in recognition
of the systematic processes that contribute to intravenous KCl errors in hospitals, the Australian Council for
Safety and Quality in Health Care (2003) posted its
‘Medication alert 1- potassium chloride, intravenous’.
This alert, outlining a systematic approach to preventing
the incidence and impact of intravenous KCl drug
errors, has been widely adopted by Australian health
care services. Nonetheless, nurses at the ‘sharp end’ of
KCl drug errors still face the prospect of severe
disciplinary action for their mistakes.
8. The importance of distinguishing ‘nursing errors’
Earlier in this paper, the notion of what constitutes a
‘nursing error’ was explored and its working definition
provided. In light of the discussion so far and the
emphasis that has been given to taking a ‘system
approach’ rather than a ‘person approach’ to humanerror management, it might seem that the notion of
‘nursing error’ is in itself a contradiction in terms. Some
clarification is thus required here of why it is important
to define and distinguish nursing errors and why making
such a distinction is neither inconsistent nor incompatible with a system approach to human-error management in health care. First, a system approach is
concerned not so much with de-identifying persons
who make mistakes, but to defusing the naming,
blaming and shaming that might otherwise be directed
at such persons when at the ‘sharp end’ of an error
event. A system approach makes it possible to identify a
person or category of persons (e.g., nurses) as being
located at the end of a causal chain of events without
necessarily blaming them and holding them individually
responsible for the effect (consequence). Second, distinguishing nursing errors from other kinds of errors stands
as a necessary precondition to taking a system approach
and to tracking and correcting the system processes
‘upstream’ (e.g., inadequate nursing staffing levels or
373
poor working environment of nurses (Page, 2004)) that
may have contributed to the event (e.g., a drug
administration error). Thus, paradoxically, failures in
the system often cannot be tracked, tagged and
corrected unless (and until) they become manifested at
the ‘sharp end’, viz. as an individual mishap. Third,
identifying nursing errors is critical to the development
of the profession and practice of nursing. If, for
instance, nursing activities are found to be disproportionately represented in preventable adverse-events statistics (i.e., relative to other activities), then serious
questions can be raised about the processes that may
have contributed to this situation and how the profession and practice of nursing as a whole (rather than a few
errant individuals) can be developed to respond
effectively to this disproportionate representation and,
more specifically, the system processes that may have
contributed to it. Finally, identifying and taking a
system approach to correcting errors that are distinctively ‘nursing’ enables the profession to demonstrate its
accountability and commitment to the public and to
demonstrating its commitment to assuring the quality of
its services.
9. Implications for nurse education, research and practice
Nursing, like medicine, is a stressful and intrinsically
‘risk-laden practice’ (Mulcahy and Rosenthal, 1999,
p. 14; Rosenthal, 1999, p. 143). Clinical nursing work is
carried out in situations that are largely unpredictable
and it relies heavily on qualitative assessments and
judgements about the clinical conditions of patients and
the environments in which they are being cared for.
Thus, from the moment a nurse engages in providing
nursing care, she/he runs the risk of ‘doing something
wrong’. This is because, as Rosenthal explains in
another context:
Clinical judgment is ‘acting as if’ but without
complete certainty. Most clinicians are technically
competent and knowledgeable, but this is always
circumscribed by uncertainty and emerging, sometimes unpredictable, events (Rosenthal, 1999, p. 143).
In short, nurses, like others, are ‘susceptible to error
and vulnerable to its fallout’ (Wu, 2000, p. 727).
However, in the light of new initiatives that are being
progressed for human-error management in health care,
it is important for the nursing profession to accept that
genuine mistakes made by nurses are largely the product
of ‘system flaws, not character flaws’ (Leape, 1994) and
that practitioners who make mistakes are not necessarily
‘bad’, a threat to the public interest or guilty of
unprofessional conduct (i.e., acting contrary to the
agreed and accepted standards of the profession)
ARTICLE IN PRESS
374
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
(Johnstone and Kanitsaki, 2005). This, in turn, requires
the nursing profession not just to think about new
things, but also to engage in a new way of thinking
about nursing-error management. There are a number
of areas that require attention at an educational,
research and practice level.
First, there needs to be a whole new approach to the
way patient safety and quality care is taught to and
practised by nurses. If nurses are to improve their
capacity to reduce the incidence and impact of practice
errors, they need first to understand the broad principles
of human-error management. For this to happen,
however, it is evident that sustained attention needs to
be given to systematically exploring via research and
other forums the following questions:
How do we deal with and teach students of nursing
about the uncertainties of the clinical nursing
practice?
How do we convey the realities of these uncertainties
to patients and allied health workers without undermining their trust and hope in nurses and the nursing
care services that nurses provide?
How do we improve data sets and collection of data
on the nature, incidence and cause of nursing errors?
How should we use the data and other information
collected on nursing errors?
How do we deal with nursing errors and what is the
best way to manage them?
How should we deal with non-reporters (e.g., should
nurses who fail to report errors or their ‘near miss’ be
sanctioned?)
How are the victims of nursing errors best served
(acknowledging here that when serious mistakes are
made, it is not only the patient who is the victim, but
also the nurse who is often left the ‘second victim’
(see also Wu, 2000))?
How might we improve the strategies and incentives
for a cultural change in this area?
What kind of information is required to inform
the development of processes aimed at improving
patient safety and quality care in nursing
domains? (adapted from Mulcahy and Rosenthal,
1999, p. 5).
Second, there needs to be a change in the culture of
expectation that nurses (and students of nursing) ‘must
know everything’—often reflected in teaching methods
that treat students of nursing (both undergraduate and
postgraduate) as ‘empty vessels’ that need to be filled
with knowledge (Greenwood, 2000). Instead, we need to
foster a culture of inquiry and recognition that we do
not know—and indeed it is not possible to know—
everything. Third, there needs to be a major shift in the
way error reporting and complaints are viewed and
handled. Rather than seeing error reports and complaints as a reason to name, blame and shame individuals, they need to be viewed as ‘learning treasures’- that
is, as valuable opportunities to learn and to improve
(Walshe, 1999). Finally, we need to foster inquiry into
and improve our understanding of error reporting
processes in nursing, how nurses tend to respond to
such processes, how nurses account for their practice
errors, the emotional impact of being the subject of a
practice error report and what actions they may take
following a report or complaint being made about them
(adapted from Mulcahy and Rosenthal, 1999, p. 5; see
also Pugh, in progress).
For the above approaches to succeed, however, there
also needs to be a major law reform and a significant
shift away from the punitive approach (e.g., disciplinary
action, criminal prosecution) that has been taken
traditionally in response to nursing practice errors. As
an increasing number of scholars are pointing out, not
only is punitive litigation directed at errant practitioners
an inefficient mechanism for deterring future error and
even for providing compensation for victims, it is also
unacceptably setting back the patient safety agenda
(May and Aulisio, 2001; see also Bovbjerg et al., 2001;
Dickens, 2003; Liang, 2001; Sharpe, 2003). There is also
an emerging consensus that unless the law is substantially reformed apropos, giving practitioners who make
and report honest errors complete immunity from
disciplinary action and prosecution, the new approach
to improving patient safety that is being advocated
globally will fail (Andrus et al., 2003).
10. Conclusion
Human error in health care domains carries a high
burden of cost and suffering for all involved. Neither the
nursing profession nor others in the field can afford to
turn their backs on the opportunities that are now
available to learn from practice errors and to use the
lessons learned to help prevent future errors
from occurring. To turn our backs away from this
learning opportunity would be akin to what one
commentator describes as ‘19th-century practitioners
turning away from the new scientific discoveries
available to improve 19th-century medicine’ (Pinkus,
2001, p. 130).
The open admission of mistakes is not only the ‘right
thing to do’ morally, but is also of practical importance
for the development of the profession. However, so long
as legal and organisational processes conspire against
nurses making open disclosures of their practice errors,
the ethical aspirations made explicit in various professional position statements and nursing codes of ethics
concerning patient safety will be very difficult to uphold,
thereby enabling the status quo to endure.
ARTICLE IN PRESS
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
References
Amoore, J., Ingram, P., 2002. Quality improvement report:
learning from adverse incidents involving medical devices.
British Medical Journal 325 (2 August), 272–275.
Anderson, D., Webster, C., 2001. A systems approach to the
reduction of medication error on the hospital ward. Journal
of Advanced Nursing 35 (1), 34–41.
Andrus, C., Villasenor, E., Kettelle, J., Roth, R., Sweeney, A.,
Matolo, N., 2003. To err is human: uniformly reporting
medical errors and near misses, a naı̈ve, costly, and
misdirected goal. Journal of American College of Surgeons
196 (6), 911–918.
Antonow, J., Smith, A., Silver, M., 2000. Medication error
reporting: a survey of nursing staff. Journal of Nursing Care
Quality 15 (1), 42–48.
Australian Council for Safety and Quality in Health Care, 2003.
Medication alert 1—potassium chloride, intravenous. http://
www.safetyandquality.org/articles/ACTION/kcalertfinal1.pdf,
(accessed 26.10.04).
Bagian, J., Lee, C., Gosbee, J., DeRosier, J., Stalhandske, E.,
Williams, R., Burkhardt, M., 2001. Developing and
deploying a patient safety program in a large health care
delivery system: you can’t fix what you don’t know about.
Journal of Quality Improvement 27 (10), 522–530.
Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K.,
Jamison, D., 2002. Individual, practice, and system causes
of errors in nursing: a taxonomy. Journal of Nursing
Administration 32 (10), 509–523.
Berry, M., 2000. Managing inherent risks of evolving patient
care delivery models. Journal of Healthcare Risk Management 20 (2), 22–33.
Bolsin, S., 2003. Whistle blowing. Medical Education 37,
294–296.
Bovbjerg, R., Miller, R., Shapiro, D., 2001. Paths to reducing
medical injury: professional liability and discipline vs.
patient safety—and the need for a third way. Journal of
Law, Medicine & Ethics 29 (3/4), 369–380.
Brennan, T., Leape, L., Laird, L., Hebert, L., Localio, R.,
Lawthers, A., Newhouse, J., Weiler, P., Hiatt, H., 1991.
Incidence of adverse events and negligence in hospitalised
patients: results of the Harvard medical practice Study I.
New England Journal of Medicine 324 (6), 370–376.
Cho, S., 2001. Nurse staffing and adverse patient outcomes: a
systems approach. Nursing Outlook 49 (2), 78–85.
Clark, R., 2004. Health Care and Notions of Risk. Therapeutic
Guidelines Ltd, Melbourne.
Cohen, M., 1997. Colorado nurses trial: learning from
medication errors. Nursing 27 (10), 26.
Cohen, M., 2000. Why error reporting systems should be
voluntary. British Medical Journal 320 (7237), 728–729.
Committee on Quality of Health Care in America, Institute of
Medicine, 2001. Crossing the Chasm: A New Health System
for the 21st Century. National Academy Press, Washington
DC.
Department of Health, 2000. An Organisation with a Memory:
Report of an Expert Group on Learning from Adverse
Events in the NHS. Department of Health, London.
Dickens, B., 2003. Medical errors: legal and ethical responses.
International Journal of Gynecology and Obstetrics 81 (1),
109–114.
375
Faugier, J., Ashworth, G., Lancaster, J., Ward, D., 1997. An
exploration of clinical risk management from a nursing
perspective. NT Research 2 (2), 97–107.
Greenwood, J., 2000. Critique of the graduate nurse: an
international perspective. Nurse Education Today 20 (1),
17–23.
Hall, J., 2003. Legal consequences of the moral duty to report
errors. Journal of Nursing Administration 5 (3), 60–64.
Hart, E., Hazelgrove, J., 2001. Understanding the organisational context for adverse events in the health services: the
role of cultural censorship. Quality in Health Care 10 (4),
257–262.
Hayward, R., Hofer, T., 2001. Estimating hospital deaths due
to medical errors: preventability is in the eye of the reviewer.
Journal of American Medical Association 286 (4), 415–420.
International Council of Nurses, 2002. Position Statement: Patient
Safety. ICN, Geneva. http://www.icn.ch/pspatientsafe.htm,
(accessed 22.10.04)
Johnstone, M., 1994. Nursing and the Injustices of the Law.
WB Saunders/Bailliere Tindall, Sydney.
Johnstone, M., 2004a. Patient safety, ethics and whistleblowing:
a nursing response to the events at the Campbelltown and
Camden Hospitals. Australian Health Review 28 (1), 13–19.
Johnstone, M., 2004b. Bioethics: A Nursing Perspective, fourth
ed. Elsevier Australia, Sydney.
Johnstone, M., Kanitsaki, O., 2005. Processes used for
disciplining nurses for unprofessional conduct of a ‘serious’
nature: a critique. Journal of Advanced Nursing 50 (4),
363–371.
King, G., 2001. Perceptions of intentional wrongdoing and peer
reporting behaviour among registered nurses. Journal of
Business Ethics 34 (1), 1–13.
King, G., Hermodson, A., 2000. Peer reporting of coworker
wrongdoing: a qualitative analysis of observer attitudes in
the decision to report versus not report unethical behaviour.
Journal of Applied Communication Research 28 (4),
309–329.
Kingston, M., Evans, S., Smith, B., Berry, J., 2004. Attitudes of
doctors and nurses towards incident reporting: a qualitative
analysis. Medical Journal of Australia 181 (1), 36–39.
Kohn, L., Corrigan, J., Donaldson, M. (Eds.), 2000. To Err is
Human: Building a Safer Health System. National Academy
Press, Washington DC.
Kuhn, A., Youngberg, B., 2002. The need for risk management
to evolve to assure a culture of safety. Quality & Safety in
Health Care 11 (2), 158–162.
Lawton, R., Parker, D., 2002. Barriers to incident reporting in a
healthcare system. Quality & Safety in Health Care 11 (1),
15–18.
Leape, L., 1994. Error in medicine. Journal of the American
Medical Association 272 (23), 1851–1857.
Leape, L., Brennan, T., Laird, L., Lawthers, A., Localio, R.,
Barnes, B., Hebert, L., Newhouse, J., Weiler, P., Hiatt, H.,
1991. The nature of adverse events in hospitalised patients:
results of the Harvard Medical practice Study II. New
England Journal of Medicine 324 (6), 377–384.
Liang, B., 2001. The adverse event of unaddressed medical
error: identifying and filling the holes in the health-care and
legal systems. Journal of Law, Medicine & Ethics 29 (3–4),
346–368.
ARTICLE IN PRESS
376
M.-J. Johnstone, O. Kanitsaki / International Journal of Nursing Studies 43 (2006) 367–376
Lilford, R., 2002. Patient safety research: does it have legs?
Quality & Safety in Health Care 11 (2), 13–114.
May, T., Aulisio, M., 2001. Medical malpractice, mistake
prevention, and compensation. Kennedy Institute of Ethics
Journal 11 (2), 135–146.
Mission, J., 2001. A review of clinical risk management. Journal
of Quality Clinical Practice 21, 131–134.
Mulcahy, L., Rosenthal, M., 1999. Beyond blaming and
perfection: a multi-dimensional approach to medical mishaps. In: Rosenthal, M., Mulcahy, L., Lloyd-Bostock, S.
(Eds.), Medical Mishaps: Pieces of the Puzzle. Open
University Press, Buckingham, pp. 3–19.
Nexus, 1996. Hearings: Nurse F, Nurse G and Nurse H. Nexus,
2(2), p. 6 [Official newsletter published by the Nurses Board
of Victoria, Melbourne].
Nightingale, F., 1980. Notes on Nursing: What it is, and What
it is not. Churchill Livingstone, Edinburgh. (First published
1859, Harrison & Sons).
Page, A. (Ed.), 2004. Keeping Patients Safe: Transforming the
Work Environment of Nurses. National Academy Press,
Washington DC.
Pinkus, R., 2001. Mistakes as a social construct: a historical
approach. Kennedy Institute of Ethics Journal 11 (2),
117–133.
Pugh, D.Study into the phenomenon of unprofessional conduct
in nursing. Ph.D. Thesis, RMIT University, Melbourne, in
progress.
Rasmussen, J., Jensen, A., 1974. Mental procedures in real-life
tasks: a case study of electronic troubleshooting. Ergonomics 17, 293–307.
Reason, J., 1990. Human Error. Cambridge University Press,
New York.
Reason, J., 2000. Human error: models and management.
British Medical Journal 320 (7237), 768–770.
Reason, J., 2001. Understanding adverse events: the human
factor. In: Vincent, C. (Ed.), Clinical Risk Management,
second ed. BMJ Books, London, pp. 9–30.
Rosenthal, M., 1999. How doctors think about medical
mishaps. In: Rosenthal, M., Mulcahy, L., Lloyd-Bostock,
S. (Eds.), Medical Mishaps: Pieces of the Puzzle. Open
University Press, Buckinhgam, pp. 141–153.
Runciman, W., Moller, J., 2001. Iatrogenic injury in Australia.
Report for the National Health Priorities and Quality
Branch of the Department of Health and Aged Care of the
Commonwealth Government of Australia, Australian Patient Safety Foundation. www.apsf.net.au (accessed 04. 06.
04).
Secker-Walker, J., Taylor-Adams, S., 2002. Clinical incident
reporting. In: Vincent, C. (Ed.), Clinical Risk Management:
Enhancing Patient Safety, second ed. BMJ Books, London,
pp. 419–438.
Sharpe, N., 2003. Special Supplement: Promoting patient
safety: an ethical basis for policy deliberations. Hastings
Center Report 33 (5), S1–S19 Special Supplement.
Smetzer, J., 1998. Lesson from Colorado: beyond blaming
individuals. Nursing Management 29 (6), 49–51.
Vincent, C. (Ed.), 2001. Clinical Risk Management, second ed.
BMJ Books, London.
Walker, S., Lowe, M., 1998. Nurses’ views on reporting
medication incidents. International Journal of Nursing
Practice 4 (2), 97–102.
Walshe, K., 1999. Medical accidents in the UK: a wasted
opportunity for improvement? In: Rosenthal, M., Mulcahy,
L., Lloyd-Bostock, S. (Eds.), Medical Mishaps: Pieces of the
Puzzle. Open University Press, Buckingham, pp. 59–73.
Webster, C., Anderson, D., 2002. A practical guide to the
implementation of an effective incident reporting scheme to
reduce medication error on the hospital ward. International
Journal of Nursing Practice 8 (4), 176–183.
Wilson, R., Runciman, W., Gibberd, R., Harrison, B., Newby,
L., Hamilton, J., 1995. The quality in Australian health care
study. Medical Journal of Australia 163 (6 November),
458–471.
World Health Organisation (WHO), 2001. Quality of care:
patient safety: report by the Secretariat. Executive Board
109th Session, Provisional agenda item 3.4 (EB109/9) 5
December. www.who.int/, (accessed 10.09.03).
World Health Professions Alliance, 2002. Health professionals
call for priority on patient safety. Press release 29 April
2002. www.whpa.org, (accessed 03.10.03).
Wu, A., 2000. Medical error: the second victim. British Medical
Journal 320 (7237), 726–727.