Ann Cook, Helena Hoas, Katarina Guttmannova & Joyner, Jane
“An Error by Any Other Name.”
American Journal of Nursing, 2004, 104(6): 32-44.
This article presents and summarizes the findings from a multi-method study conducted over 4 years in 29 rural hospitals of nine Western states. The research includes 7 sub-studies designed to examine the recognition and reporting of errors, as well as attribution of responsibility for patient safety. Our study shows healthcare providers uniformly identified patient safety as a serious concern. Moreover, most reported that they worked within institutions that embraced a “no shame, no blame,” approach to reporting of medical errors and adverse events. The three types of errors most consistently identified and reported in each hospital were: medication errors, patient falls, and errors caused by illegible handwriting identified.
The findings also showed, however, that healthcare providers’ recognition of errors may be limited by professional differences in expectations and personal beliefs. Since most of the recognized, reported, and charted errors fall within the nursing practice, patient safety was viewed as primarily a nursing responsibility. However, only a minority of nurses reported that they have participated in patient-safety and error-reporting processes. The authors suggest that efforts to improve patient safety require shared responsibility among all healthcare team members in a system-wide approach. Key strategies include: a shared vision of safety as a priority, a commitment to replacing systems that do not work, interdisciplinary training, and accessible resources that support critical thinking.