Comprehensive Study Guide on Nursing Error Reporting and Ethics

Participant and Author List

• Audrey Bruening

• Jillian Hamberger

• Emma Kellum

• Ashley Strohmeier

• Stephanie Visciano

Definitions and Ethical Foundations

• Ethical Dilemma: This refers to situations where a professional must choose between conflicting values, such as practicing honesty versus a fear of consequences, or choosing between patient safety and self-protection.

• Error Reporting: The standard procedure of reporting a medical mistake immediately to a clinical supervisor. It requires accurate documentation without post-incident changes or attempts to assign blame, while strictly adhering to facility-specific policies.

• Negligence: A failure to provide the expected proper care. Named examples include rushing through tasks or failing to double-check medication dosages.

• Malpractice: A specific form of professional negligence that results in harm to the patient.

• Intentional Tort: A deliberate act intended to cause harm; these are noted as being rare within the context of medical errors.

Etiology of Medical Errors

• Errors typically occur due to systemic and personal stressors, including:     - Fatigue resulting from long shifts.     - Burnout and high levels of stress.     - Distractions within the clinical environment.     - Heavy workloads.     - Poor communication among the healthcare team.

The Reporting Process: Why and When

• Rationale for Reporting: The primary goals are to prevent future errors, improve the overall safety of the patient, and encourage professional accountability.

• Legal Protection (PSQIA): Nurses are protected by the Patient Safety and Quality Improvement Act (PSQIA). This is a voluntary national error reporting system designed to encourage providers to report mistakes without the fear that information will be used against them professionally or legally (Howard et. al $147$).

• Timing: Errors must be reported immediately upon discovery.

• Scope of Reporting: Any situation posing harm to a patient must be reported, including:     - Equipment malfunctions.     - Medication errors.     - Documentation errors.     - Any practice that is deemed illegal or unethical.

• Core Philosophy: Reporting should uphold honesty and prioritize collective learning over individual blaming.

Procedural Steps for Reporting Errors

• Recognition: The nurse must first accurately identify that an error has occurred.

• Immediate Patient Safety: The first priority is to ensure the safety of the patient (Ramsey $20$).

• Direct Communication: If appropriate, address the issue with the person involved directly (Ramsey $20$).

• Chain of Command: Report the issue to a supervisor, administrator, or healthcare provider (Ramsey $21$).

• Formal Policy: Adhere to institutional policies regarding formal reporting protocols (Ramsey $21$).

• Fact-Based Documentation: Document only the objective facts of the situation.

• Continued Follow-Up: Notify a higher authority if patient safety remains at risk during the follow-up period (Ramsey $20$).

• Quality Improvement: Participate in the review of errors to help improve future practice through committees, peer review processes, or investigations (Ramsey $20$).

Consequences of Non-Reporting

• National Statistics: According to the Institute of Medicine, it is estimated that between $44,000$ and $98,000$ patients die every year as a direct result of medical errors (Paterick et. al $205$).

• Nurse Deterrents: Nurses often feel nervous to report mistakes due to the fear of legal repercussions in court (Howard $151$).

• Professional Responsibility: Failing to report an error is considered a breach of the nursing code of ethics (Wolf & Hughes). The primary role of a nurse is to protect patients from harm and promote safe, ethical care.

• Legal Risks: Non-reporting does not avoid trouble; instead, it increases risk for both the patient and the nurse, potentially leading to legal action for negligence.

Case Study: Quick Debrief Dialogue

• Scenario Subject: Stephanie (Student Nurse).

• Question #1: What could Stephanie (the student nurse) have done better after noticing her error?     - Response: She should have talked to Jillian or Audrey immediately to report her mistake.

• Question #2: What are some steps Stephanie could take to help avoid this situation in the future?     - Response: Always double-check the dosage administration before giving the medication to the patient.

• Question #3: Why is it important to report errors immediately instead of waiting it out?     - Response: For patient safety; it allows for the immediate monitoring of the patient's health as soon as the error is made.

NCLEX Style Practice and Rationales

• Practice Question #1: A nurse accidentally administers the wrong dose to a patient. Which action should the nurse take first?     - A. Complete an incident report.     - B. Tell an older nurse who you trust.     - C. Assess the patient's condition.     - D. Wait to see if the patient has a reaction before further steps.

• Rationale for Question #1: Assessing the patient's condition is the top priority regardless of whether physical symptoms are present. After caring for the patient and ensuring safety, the incident should then be reported.

• Practice Question #2: A nurse witnesses another nurse make a medication error but refuses to report it. What is the best action to take?     - A. Ignore the situation.     - B. Report the error according to facility policy.     - C. Confront the nurse aggressively.     - D. Wait to see if the patient develops symptoms.

• Rationale for Question #2: Patient safety outweighs personal discomfort. Nurses have a legal and moral duty to report unsafe practices, even involving close friends or coworkers. Reporting is essential for personal and collective improvement.

Creating a Caring and Healing Environment

• Nurse-to-Nurse Dynamics:     - Benefits: Promotes collaboration and teamwork; encourages learning from mistakes; improves overall communication.     - Pitfalls: Fear of blame or punishment; decreased confidence in professional abilities; increased levels of stress and anxiety.

• Nurse-to-Patient Dynamics:     - Benefits: Builds trust through transparency and honesty; supports patient-centered care; improves overall safety.     - Pitfalls: Loss of trust in the healthcare provider; increased patient anxiety; fear of undergoing treatment or care; potential for patient dissatisfaction.

Prevention Strategies and Principles

• Core Principles: Beneficence (doing what is best for the patient) and Nonmaleficence (avoiding harm) guide healthcare providers. Moral conflicts may arise when balancing projected benefits against possible patient risks.

• Harm Mitigation: Errors cause harm to the patient, the individual who made the error, and the healthcare system itself (Kalra, Kalra, & Baniak, $2013$).

• Strategic Recommendations:     - Rules and Policies: Involve nurses in developing clear, detailed policies for organizational safety.     - Communication Improvements: Ensure messages are clear and prompt. Utilize handoff tools such as SBAR (Situation, Background, Assessment, Recommendation) or task debriefing to minimize communication failures.     - Systemic Safeguards: Implement checklists, reminders, and double-checks to reduce errors in high-risk situations.

Scholarly References

• Agency for Healthcare Research and Quality. (n.d.). Error reporting and disclosure. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

• Agency for Healthcare Research and Quality. (n.d.). Medication administration safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

• Howard, J., Levy, F., Mareiniss, D. P., Patch, M., Craven, C. K., McCarthy, M., EpsteinPeterson, Z. D., Wong, V., & Pronovost, P. ($2010$). A Review of the Medical Literature and Analysis. Journal of Patient Safety, $6(3)$, $147$-$152$. JSTOR.

• Paterick, Z. R., Paterick, B. B., Waterhouse, B. E., & Paterick, T. E. ($2009$). The Challenges to Transparency in Reporting Medical Errors. Journal of Patient Safety, $5(4)$, $205$-$209$. JSTOR.

• Ramsey, G. ($2005$). Nurses, Medical Errors, and the Culture of Blame. The Hastings Center Report, $35(2)$, $20$.

• Sorrell, J. ($2017$, March $7$). Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare | OJIN: The Online Journal of Issues in Nursing.

• StatPearls Publishing. ($2023$). Hypoglycemia (Nursing).

• Wolf, Z. R., & Hughes, R. G. ($2020$). Error Reporting and Disclosure. National Library of Medicine; Agency for Healthcare Research and Quality (US).