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Newly qualified nurses often fear making or identifying a clinical error so it is vital to know how best to prevent errors and manage them when they have occurred
It is almost inevitable that every nurse will have to deal with a clinical error at some stage in their career. Doing so may get easier as nurses develop their experience but, for newly qualified nurses, the fear of making a mistake and not being sure how to best manage it can be stressful. This article looks at the most common clinical errors that are made, explains where to find the policies and procedures that should be followed, and highlights tips and tools that can be used to help rectify the issue or prevent it from happening in the first place.
Citation: Cathala X, Moorley C (2020) Managing errors and mistakes: guidance for newly qualified nurses. Nursing Times [online]; 24/06/2020.
Authors: Xabi Cathala is lecturer, School of Health and Social Care/Institute of Vocational Learning; Calvin Moorley is associate professor for nursing research and diversity in care, School of Health and Social Care/Adult Nursing & Midwifery Studies; both at London South Bank University.
Making a clinical error is a fear most nurses have, especially newly qualified nurses (NQNs). However, everyone makes mistakes, for the simple reason that we are human; no nurse can say they have never made a mistake during their career. Nevertheless, there are different types of errors and some have less harmful outcomes than others. What is important is how we prevent these from occurring and the way we manage them. This article examines the most common mistakes in nursing – learning from them is crucial to better operational performance and improve patient safety. It provides guidance on how to manage errors and why is it important to address them.
Grober and Bohnen (2005) defined a medical error “as an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”. This may also be applicable to nursing. Most nurses will hear about and discuss making mistakes and errors during their career, and reporting incidents and errors via Datix, the incident reporting system used in the UK.
During the literature search for this article, it was difficult to find published work on nursing mistakes; publications focused on medication errors, sidelining other mistakes, such as miscommunication, which can occur after a failure to confirm or clarify medical orders with a health professional or a failure to simply ask for help. From all the articles reviewed, the message to take home was the same: errors affect patient safety and safety is a fundamental aspect of nursing care (Marques and Vinagre, 2018).
Errors or mistakes are usually classified as preventable or unpreventable events (Brennan et al, 2004). In the UK, the term ‘near miss’ is used to describe a patient having been exposed to a hazardous situation when no injury or harm is sustained due to chance or early detection (World Health Organization, 2005).
Preventable events should not occur and are often referred to as ‘never events’. Elliott et al (2018) defined never events as serious incidents that are preventable if national guidance and recommendations are available and applied by healthcare workers. NHS Improvement published a list of never events (Box 1), along with a never-events policy and framework (NHS Improvement, 2018a) to help healthcare providers deliver safe, high-quality, compassionate care that is financially sustainable. If a preventable event has taken place, a breach has occurred during the care delivery process and the guidance/recommendations have not been implemented.
Box 1. Never events
- Wrong-site surgery
- Wrong implant/prosthesis
- Retained foreign object post-procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower or curtain rails
- Falls from poorly restricted windows
- Chest or neck entrapment in bed rails
- Transfusion or transplantation of ABO-incompatible blood components or organs
- Misplaced naso- or oro-gastric tubes
- Scalding of patients
- Unintentional connection of a patient requiring oxygen to an air flowmeter
Source: NHS Improvement (2018b)
From the literature reviewed, the most common mistakes in nursing appear to be related to:
- Infection prevention and control;
In the UK, there is a clear drugs administration and management process in place, set out by the Royal Pharmaceutical Society of Great Britain (2005). For every drug, a nurse has to follow a step-by-step process to ensure its safe administration. This is specifically the case for controlled drugs – in the UK, it is a legal requirement that two registered nurses must check and sign the prescription, and check the drug (name, concentration, expiry date, any previous adverse reaction to the drug or allergies and calculation) together; the same also applies to most organisations’ local practice policies on intravenous medications (Royal Pharmaceutical Society and Royal College of Nursing, 2019; RPS, 2005). However, despite this stringent process, mistakes still happen. Elliott et al (2018) estimated that 237 million medication errors occur in England per year; these are not limited to nurses but all healthcare workers whose role includes medicines management. Some examples are:
- Administration without a valid prescription;
- Wrong dose, medication or route;
- Medication administered to which the patient was allergic;
- Late/early administration;
- Wrong patient;
- Omitted medication;
- Failure to record;
- Wrong calculation.
These can be summarised as falling into the following categories:
- Monitoring patient condition/documenting (Jennings et al, 2011; Choo et al, 2010).
Medication errors are the most researched and studied (Hayes et al, 2015), perhaps because they are preventable and have a direct impact on patient safety as well as nurse performance.
Documentation is an important aspect of nursing practice. Keeping patients’ records up to date and accurate is a difficult task, especially during 12-hour shifts, but it is the nurse’s responsibility to maintain documentation (Nursing and Midwifery Council, 2018). Some of the mistakes around documentation are:
- Inaccurate recordings;
- Missing information;
- Entry against the wrong patient (Smeulers et al, 2015).
Infection prevention and control
Infection prevention and control is a central concern in nursing practice because the risk of infection is everywhere and can potentially harm patients. (Khan et al, 2017). For each task, nurses should think about minimising the risk of infection. Regardless of the difficulty of the task, infection prevention and control procedures must be adhered to at all times to ensure patient safety. Failure to adhere to isolation protocol, non-compliance with the hand washing or hygiene regimens, poor use of aseptic non-touch technique procedure are all errors that have been reported (Storr et al, 2013).
Nursing is part of a multidisciplinary care process and communication is essential between each discipline to ensure safe patient care (Randmaa et al, 2014). The ability to communicate accurately and promptly is a skill that nurses acquire with experience. Some examples of miscommunication in healthcare are:
- Wrong information is communicated;
- Doctor is called without accurate or sufficient information [on which they can provide advice;
- Delay in escalating information;
- Misunderstandings between healthcare workers (Greenberg et al, 2007).
We suggest all newly qualified nurses use NHS Improvement’s (2018c) SBAR (situation, background, assessment, recommendation) tool, which provides a structured approach when communicating with medical professionals or other members of the multidisciplinary team (Box 2).
Box 2. The SBAR tool
The SBAR (situation, background, assessment, recommendation) tool outlines a structured approach that can be used when communicating with other health professionals.
S – situation
- Identify yourself and the site/unit you are calling from
- Identify the patient by name and the reason for your communication
- Describe your concern
B – background
- Give the patient’s reason for admission
- Explain significant medical history
- Give the person receiving the information details of the patient’s background – that is, admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. For this part in the process, you will need to have collected the relevant information from the patient’s chart and notes
A – assessment
- Vital signs
- Contraction pattern
- Clinical impressions, concerns
R – recommendation
What is your recommendation? What would you like to happen by the end of the conversation? Any advice given on the phone needs to be repeated back to ensure accuracy.
- Explain what you need – be specific about request and time frame.
- Make suggestions.
- Clarify expectations
Source: NHS Improvement (2018c)
Much work has been conducted on falls in hospital. Pre-assessment, risk assessment and manual handling training are some of the procedures in place that aim to reduce patient falls (Melin, 2018). However, falls are still occurring and carry a high potential risk of patient injury, particularly in older patients (Zecevic et al, 2017). As newly qualified nurse, to ensure patient safety, it is essential to:
- Fully assess the patient;
- Identify any risk;
- Have in place protocols and equipment required to ensure patient safety.
If a patient is believed to be at risk of a fall and the nurse is unable to provide the necessary prevention or aids needed, speak to the nurse in charge and document the concerns.
“Never hide a mistake, as this places patient safety at risk; highlighting an error allows its correction and keeps the patient safe”
Managing and reporting mistakes
All hospitals have protocols and policies to help with the prevention and management of mistakes. Refer to the relevant policy to be aware of the procedures in place. Always double-check if you have any doubts about patient care, practices or your colleagues’ actions: if you feel something is not right or does not make sense, look for any mistakes or errors. You can also ask a colleague to check to confirm your thinking – a second set of eyes is always useful.
If a mistake is found, your actions should be in the best interests and safety of the patient. For example, if you identify an infused medication running at the incorrect rate, check the patient is safe, recalculate the rate with another colleague and correct the administration accounting for the medication’s pharmacokinetic and pharmacodynamic properties (for example, inotropes or vasoconstriction medication). Once the patient’s safety is established, the event needs to be escalated to the nurse in charge. An investigation to understand why this mistake happened should take place and a report, such as Datix, should be created by the nurse responsible for the patient’s care. This report contains the different essential information that can help people to learn from the mistake and how to prevent it recurring. Never hide a mistake, as this places patient safety at risk; highlighting an error allows its correction and keeps the patient safe.
Reporting an error allows an understanding of how and why it occurred (Wolf and Hughes, 2008). The purpose of reporting is not to lay blame on the person who made the mistake, but to improve practice. Knowing the reason for the error an opportunity to:
- Change practice;
- Put in place an action plan to make sure this mistake will never happen again (Johnstone and Kanitsaki, 2006).
The best way to stop mistakes happening is through prevention. However, to be able to prevent mistakes, we need to understand their causes; if there is no report, this cannot be done. Reporting errors is an important aspect of nurse accountability.
Duty of candour is a statutory duty that requires all health and adult social care providers registered with the Care Quality Commission to be open with people when things go wrong (CQC, 2015). The General Medical Council and Nursing and Midwifery Council have produced guidance on being honest and open, and what to do when things go wrong. There are four main steps to follow:
- Tell the patient when something has gone wrong;
- Apologise to the patient;
- Offer an appropriate solution or support to remedy the situation (if possible);
- Explain fully to the patient the long- and short-term effects of what has happened (GMC and NMC, 2015).
Before following these steps, newly qualified nurses should speak to the nurse in charge and/or their preceptor
“The purpose of reporting is not to lay blame on the person who made the mistake, but to improve practice”
Errors and mistakes can occur in nursing, and it is important to reduce or prevent them; reporting helps to achieve this through the identification of patterns that are rectifiable. Nurses should never be afraid to report a mistake and it is their duty to improve practice and keep their patients safe. Making mistakes is human, but not reporting it is a professional misconduct – do not hide; report.
- Every nurse is likely to make a mistake at some point in their career
- Mistakes can be preventable or unpreventable
- Preventable errors are known as ‘never events’
- All staff should be aware of their employer’s error reporting policy
- Reporting mistakes is a vital part of preventing their recurrence
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