INSTITUTE OF MEDICINE REPORT

There have always been medical and nursing errors, and these errors have always been of concern to both practitioners and patients. In 1998 the IOM captured the attention of both the media and the public when it published its landmark report To Err Is Human (Kohn et al., 2000) and identified the pervasive reality of errors related to health care. Since then, patient safety has become an overriding concern of the public at large, and some characterize this concern as a crisis of faith.

The IOM produced a second report in the fall of 2004 entitled Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004). Several aspects of the report include implications for research in practice breakdown. Of particular interest is Recommendation 7-2.

In the United States, the most appropriate place to examine this phenomenon would occur at the state level, through the state boards of nursing. This is because these boards are charged with the task of addressing key issues that are informed by the principles that guide their actions.

THE WORK OF BOARDS OF NURSING

The work of boards of nursing in the United States is complex for several reasons:

CUTBACKS, NURSING SHORTAGES, REDUCED HOSPITAL STAYS

Suboptimal institutional environments impede safe patient care. Many complex elements have contributed to this current crisis of faith in the health care system. Specifically, these elements in the form of errors came to the forefront as health care institutions implemented cutbacks in nurse-patient staffing ratios, increased nursing workload, overtime, and temporary employees. These cutbacks were exacerbated by the trend of shorter hospital stays for patients who were acutely ill and, in turn, some of the checks and balances that helped ensure patient safety were also eliminated. The nursing shortage further complicates the situation. This is partly because the complexity that results from reduced time for hospital stays and its concomitant compressed time allotment requires not only more nurses but nurses with higher levels of competence to assess, synthesize, and coordinate patient care needs.

CREATING A FAIR AND JUST HEALTH CARE CULTURE

Concerned health care organizations have recognized the complexity of these trends and their impact on practice breakdown. They worked to shift a health care culture that emphasized blaming the individual to one that looked to improve performance of the system and to reduce systems errors. Some experts have called for a no-blame culture as the solution to the problems resulting from fear and intimidation from error management. Much has been written about these no-blame cultures, viewed as a key mechanism to reduce errors and as an approach to what has evolved as a patient safety movement.

Most health care professionals recognize that shame, blame, and punishment for mistakes do not improve patient safety. In many situations, patient safety is compromised as situations are not fully analyzed and corrected for fear of further punishment. Many now recognize that a nonconstructive position is one in which an either-or position is taken—that is, where either the individual or the system is determined to be at fault, or where the system is always at fault and the individual is the victim. Rather, the desired expectation is a culture characterized by fairness and justice.

A just culture for practice breakdown management is one in which the reality of the environment, organizational cultures, and missteps are viewed as critical learning opportunities for patient safety, while also addressing carelessness, inattentiveness, and substandard practice as well as intentional misconduct in any work environment (Marx, 2001). The goal is to avoid the tendency to blame individuals for patient safety issues when the error is unintentional and is usually a product of many forces and mishaps that led to the practice breakdown. However, a just culture demands attention, repair, remediation, and discipline of those professionals who willfully ignore their professional standards. A just culture requires mutual support for a difficult and complex job, accountability for meeting the standards of good practice by all workers, and rigorous attempts to protect the public from unsafe practices. An additional goal is to avoid the tendency to blame individuals for patient safety issues when, in fact, more factors are involved than one person’s actions alone. Shared practice responsibility is a critical consideration in addition to separate considerations of the individual and the health care system’s contributions to practice breakdown.

An oppositional argument about either an individual or a systems approach is wrongheaded, since both are required in addition to carrying out the notions of good and upholding the standards of good practice of any person who is a licensed professional (Benner et al., 2002; Page, 2004). Such an oppositional view usually posits the individual as an isolated individual rather than a member-participant of a professional practice community that has publicly made a commitment to uphold the notions of good and standards of a particular profession. If the individual imagined is a competitive individual (as in an extremely competitive business model), then there can be no accounting for the moral sources and collective standards of practice, commitment to good practice, skilled know-how, ethos, and participation in the formative outcomes of an accredited professional educational program. Accrediting bodies such as the State Board of Registered Nurses accredit schools of nursing for imparting skilled know-how, knowledge of the discipline, and ethical comportment, which includes both self-improving practice and safe practice. Rather than thinking of the individual as self-maximizing or competitive, in a professional practice one needs to think of professionals (nurses, doctors, lawyers, clergy, etc.) as members-participants of the profession, committed to the notions of good internal to the practice (MacIntyre, 1984) and formed by their educational processes to have a fiduciary responsibility to their patients, clients, and parishioners.

Yet, Page (2004) and her colleagues point out:

If it were possible to make medicine absolutely scientific technical certainties with no unresearched aspects and no great individual variations in patients or in diseases/injuries, then a closed system designed to be “error free” would be possible, as is the case for manufacturing processes that are functioning well under tightly controlled circumstances. But medicine and nursing require professionals who are well educated, skillful, and ethically committed to patients’ well-being because professional skill and judgment are required, even as the best scientific evidence for practice is used. Medical and nursing clinical situations, unlike well-controlled manufacturing processes, are underdetermined, open ended, and highly variable, and therefore require highly professional judgment and skilled know-how by nurses and physicians who are committed to act well on behalf of the patient’s best interests. Systems in health care delivery are open systems. In health care, systems engineering focuses on the structures, processes, and functions of an open living system in relation to inputs and outcomes. Constant input related to knowledge, science, skill, repair, and redesign is needed for open systems. Systems analysis captures what has already happened as a result of system failure or breakdown; therefore systems repair is post hoc related to a past failure, and future oriented in designing a better system to prevent future similar failures. Professional practice communities are required to shore up and prevent immediate failure or intervene immediately in a present practice breakdown. All human systems require ongoing repair and redesign by individuals and practice communities who work together to sustain a self-improving practice.

As technology proliferates and makes work less transparent, so does the likelihood for new types of errors (Page, 2004; Reason, 1990). It is no longer possible for any one clinician to know and/or remember all the needed information for practice as noted by the Quality Chasm Report (Committee on the Quality of Health Care in America, 2001):

SHARED PRACTICE RESPONSIBILITY

All professions have the responsibility to be self-regulating and self-improving. All member participants of a professional practice have a shared public and civic responsibility to uphold the standards of the practice and to practice in such a way as to ensure ongoing improvement in the practice. Professional practice is never upheld by one individual practitioner alone. It relies in part on institutional conditions to enable good practice through system level infrastructures and organizational planning and integrity. It also relies on cooperation and collaborative effort among health care professionals who live up to the notions and standards of good practice. Complex professional practice relies on ethical, knowledge-based, and skillful practice by professionals who use clinical judgment in underdetermined clinical situations. Practice communities develop and share local practice knowledge, standards, and norms, and uphold these as members of both the local professional practice community and their larger professional communities of nursing or medicine.

The professional practice of nursing is a socially organized discipline in which its participants have been educated and tested for licensure. Professional nurses carry responsibilities to each other and to other health care team members to uphold the notions of good practice. They hold these standards of good practice in common within nursing and with other interdisciplinary team members such as physicians, pharmacists, respiratory therapists, and social workers. Professionals, by definition, have entered into a covenant to act as responsible, professional citizen members in education, licensure, and practice and through participation in professional associations (Sullivan, 2004; 2005).

The PBAP considers these professional dimensions and the relationships among the individual, the health care team, and the health care system. These elements interact in ways that honor and integrate self-governing, socially organized practice members who work professionally to participate in the everyday practices of a health care delivery team. However, a serious oversight occurs when these relationships and shared professional talents and commitments are not considered in an examination of errors. Reporting and preventing errors in any profession are serious expectations for all members of self-improving professional practice. Professional practice is impossible without these shared expectations.

THE DESIRED OUTCOME

Administrators and leaders need to support health care cultures that value questioning practices, collaborating on challenges to the health care team, and pursuing activities to promote professional development. Woods described the “holy grail [of research] that everyone wants but no one has” to include:

BOARDS OF NURSING AS SOURCES OF DATA

Boards of nursing possess a potentially rich source of data that could examine sources of nursing error and thus are well positioned to add to the body of knowledge surrounding this aspect of health care errors. This is, in part, because the kinds of errors typically reported to boards of nursing are usually serious in nature, and the knowledge from these examinations provides descriptive studies of nursing-related error. Further, the data from these studies hold great potential for developing more effective strategies to prevent and reduce serious errors at the institutional and professional practice levels.

Boards of nursing have access to data from educational and service settings. Board members can examine aggregate data and the disciplinary actions that arise from both of these settings. These reviews provide a more complex but meaningful set of data than if the service setting or the educational setting alone were the focus of examination. By studying practice breakdown, boards can promote patient safety and prevention of error by identifying nurses and nursing situations at risk for potential practice breakdowns. This new preventive regulatory role promotes proactive regulation before harm occurs rather than waiting to discipline after problems are reported.

Under the supervision and quality control of the NCSBN, this national database of nursing errors reported to state boards of nursing could become a source of additional research studies conducted by researchers, including graduate students, who want to examine practice breakdown and patient safety. For example, an outside researcher might want to focus on errors associated with the administration of medications or practice breakdown episodes related to nursing interventions, either failure to intervene or inappropriate intervention. Any of the elements or all areas of nursing practice areas could be compared locally, regionally, and nationally in order to better understand the causes of practice breakdown in nursing. This database could also shed light on a particular state’s or a particular type of institution’s comparisons of errors and patient harm with the national database. The NCSBN will encourage such outside research projects, and provide oversight and quality control as such studies evolve.

By going public and making the regulatory work of state boards of nursing more transparent to staff nurses and student nurses, the NCSBN hopes to encourage primary prevention of practice breakdown and draw attention to the central role of safety work that has long been a hallmark of nursing practice (Benner, Hooper-Kyriakidis, & Stannard, 1999). By systematically understanding the regulatory functions of the nursing profession and the major kinds of errors that nurses are likely to be involved in at some point in their careers, nurses will be better prepared to respond appropriately to practice breakdown through accurate documentation, reporting, truth telling, and immediate measures to minimize harm to the patient. The situations reported to the state boards of nursing are typically more harmful to patients, fall outside the standards of good practice, involve knowledge-skill deficits, and in those ways differ significantly from errors that would never be reported to state boards of nursing. For example, the following medication error that occurred early in the nursing career of Dianne Pestolesi, who was on the nursing faculty (Benner et al., in press), is a classic kind of error that would not be reported to the state board because the nurse took all the appropriate actions, notified the physician immediately, addressed the potential harm to the patient by altering her care, and successfully prevented the potential harm to her patient:

Ms. Dianne Pestolesi, RN, MSN, now tells this story to her students as a cautionary tale. She is equally vivid in describing her own foreboding and fears for the patient, and the patient’s actual responses. She acted responsibly and took responsibility for learning from her error. She points out to her students that she now attends to the usual match between range of dose and packaging of the medication. She was a newly graduated nurse when this incident occurred and did not yet attend to her growing practical experiential knowledge. She models for her students the most ethical response to an error. She made no effort to hide her mistake, which always compounds any error and increases the consequences for making the error. If the patient, public, and health care team members cannot trust the accuracy of documentation of care given and doses of medication given, then the patient is placed in a situation of potential further harm. Wu (2000) proclaims that providers who make an error, particularly an error that causes harm, are “the second victim” of the error.

In the context of a “shame and blame” culture, errors are more likely to be covered over, and the one committing the error is tempted to remain silent and avoid telling the patient (Wu et al., 1991). However, all these responses lack integrity and expose the patient and health care team—including the one making the error—to even more harm. Had Dianne Pestolesi covered up her error, not called the physician, and not charted this overdose, she likely would have been reported to the state board of nursing for endangering a patient. She herself would have become a victim of guilt and remorse. While she regretted her error, she took steps to avoid ever making the same mistake again by honestly reporting the error immediately and following through with protective attentive care of her patient until she was through the resulting “thyroid storm” of the high dosage. She now uses her example to let students know that everyone can and will make an error without intending to, and responding with integrity is the only possible way forward.

It is impossible to prevent all errors. Members of highly reliable organizations who also engage in high-risk work imagine all the possible pitfalls and errors that might occur (Weick & Sutcliffe, 2001). This turns out to increase the reliability of performance when it spurs persons in the highly reliable organization to imagine and correct potential errors and to take seriously and act preventively when “near misses” occur. It is an opposite response to a culture of low expectations (Reason, 1990; Wachter, 2008; Wachter & Shojania, 2004) where mistakes such as misspelling of patient names, misidentification, or underreporting of procedures are common and thus commonly overlooked as a basis for further checking. This book will contain many actual cases and cautionary tales that we hope will assist staff nurses, administrators, and student nurses in preventing recurrence of the kinds of practice breakdowns that commonly occur in nursing.

This book seeks to augment the excellent educational initiative to improve the education of undergraduate and graduate nurses about improving patient safety, sponsored by the Robert Wood Johnson Foundation and led by Linda Cronenwett. This project, Quality and Safety Education for Nurses (QSEN) (www.QSEN.org), seeks to improve education in quality improvement and patient safety in nursing education. Cronenwett and colleagues (Cronenwett et al., 2007) acknowledge that patient safety is firmly lodged in the nursing tradition and summarize some of the goals of their project as follows:

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