Strategies Used by Nurses to Recover Medical Errors in an Academic Emergency Department Setting

2.50
Hdl Handle:
http://hdl.handle.net/10755/163040
Type:
Presentation
Title:
Strategies Used by Nurses to Recover Medical Errors in an Academic Emergency Department Setting
Abstract:
Strategies Used by Nurses to Recover Medical Errors in an Academic Emergency Department Setting
Conference Sponsor:Emergency Nurses Association
Conference Year:2004
Author:Blank, Fidela S.J., RN, MN, MBA
P.I. Institution Name:Baystate Medical Center
Title:Research Coordinator, Emergency Department, Baystate Medical Center
Assistant Professor, Tufts School of Medicine
Contact Address:759 Chestnut Street, Springfield, MA, 01199, USA
Contact Telephone:(413) 794-8680
Purpose: The Institute of Medicine estimated that 98,000 people die nationwide each year because of
medical errors. The purpose of this study is to describe strategies that ED nurses use to recover medical
errors. The concept of "human recovery," as it relates to nursing, is the process of interrupting an incident
that has the potential to negatively affect the patient. When the recovery process is effective, the result is
termed a "near-miss," meaning that an adverse outcome was averted.
Design/Setting: The investigators conducted focus groups of ED nurses at a large, academic medical center
located in an urban area of Western Massachusetts. This qualitative research was approved by the
Institutional Review Board of the hospital.
Sample: Posters describing the study, with sign-up sheets, were posted in the ED break-room. Twenty staff
nurses who had at least six months of ED experience, signed informed consent forms to participate in the
study. Each nurse who participated received a stipend of $50.
Methodology: Eindhoven's near-miss model serves as the framework for this study. A list of prepared questions
was asked during the focus groups to elicit discussion of the nurse's role in the three phases of error
recovery, namely identifying, interrupting, and correcting errors. Four focus groups were run using Krueger
and Casey's methods. The sessions were audiotaped and investigators took field notes during the sessions.
The audiotapes were transcribed; transcriptions were reviewed by the investigators, and later given to participants
for any corrections. A comprehensive summary was generated. Summary transcripts were analyzed
for patterns, trends, and themes by the investigators (2 PhD nurses, 1 MN nurse, and one MD).
Results: Identified strategies include the following: One, identifying errors. The strongest strategy is having
a high level of awareness for the potential for error in their everyday practice, expressed by constant monitoring
and double-checking. Second, interrupting errors. Assertiveness is an essential trait for interrupting
errors, and mostly comes with experience. Third, correcting errors. A sense of team work and shared
responsibility is important in correcting errors; if all else fails, a strategy mentioned by most is notifying
either the supervising physician or the nurse manager.
Conclusions: ED nurses prevent many medical errors from adversely affecting patients. Key factors in
error recovery are communication and teamwork. Knowledge of strategies used by emergency nurses to
recover errors can be used in several ways to improve patient outcomes. Future research should look at
ways ED nurses can be supported by the system, in their role in error recovery. [Poster Presentation]
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleStrategies Used by Nurses to Recover Medical Errors in an Academic Emergency Department Settingen_GB
dc.identifier.urihttp://hdl.handle.net/10755/163040-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Strategies Used by Nurses to Recover Medical Errors in an Academic Emergency Department Setting</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2004</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Blank, Fidela S.J., RN, MN, MBA</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Baystate Medical Center</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Research Coordinator, Emergency Department, Baystate Medical Center<br/>Assistant Professor, Tufts School of Medicine<br/></td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">759 Chestnut Street, Springfield, MA, 01199, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(413) 794-8680</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">Del.Blank@bhs.org</td></tr><tr><td colspan="2" class="item-abstract">Purpose: The Institute of Medicine estimated that 98,000 people die nationwide each year because of<br/>medical errors. The purpose of this study is to describe strategies that ED nurses use to recover medical<br/>errors. The concept of &quot;human recovery,&quot; as it relates to nursing, is the process of interrupting an incident<br/>that has the potential to negatively affect the patient. When the recovery process is effective, the result is<br/>termed a &quot;near-miss,&quot; meaning that an adverse outcome was averted.<br/>Design/Setting: The investigators conducted focus groups of ED nurses at a large, academic medical center<br/>located in an urban area of Western Massachusetts. This qualitative research was approved by the<br/>Institutional Review Board of the hospital.<br/>Sample: Posters describing the study, with sign-up sheets, were posted in the ED break-room. Twenty staff<br/>nurses who had at least six months of ED experience, signed informed consent forms to participate in the<br/>study. Each nurse who participated received a stipend of $50.<br/>Methodology: Eindhoven's near-miss model serves as the framework for this study. A list of prepared questions<br/>was asked during the focus groups to elicit discussion of the nurse's role in the three phases of error<br/>recovery, namely identifying, interrupting, and correcting errors. Four focus groups were run using Krueger<br/>and Casey's methods. The sessions were audiotaped and investigators took field notes during the sessions.<br/>The audiotapes were transcribed; transcriptions were reviewed by the investigators, and later given to participants<br/>for any corrections. A comprehensive summary was generated. Summary transcripts were analyzed<br/>for patterns, trends, and themes by the investigators (2 PhD nurses, 1 MN nurse, and one MD).<br/>Results: Identified strategies include the following: One, identifying errors. The strongest strategy is having<br/>a high level of awareness for the potential for error in their everyday practice, expressed by constant monitoring<br/>and double-checking. Second, interrupting errors. Assertiveness is an essential trait for interrupting<br/>errors, and mostly comes with experience. Third, correcting errors. A sense of team work and shared<br/>responsibility is important in correcting errors; if all else fails, a strategy mentioned by most is notifying<br/>either the supervising physician or the nurse manager.<br/>Conclusions: ED nurses prevent many medical errors from adversely affecting patients. Key factors in<br/>error recovery are communication and teamwork. Knowledge of strategies used by emergency nurses to<br/>recover errors can be used in several ways to improve patient outcomes. Future research should look at<br/>ways ED nurses can be supported by the system, in their role in error recovery. [Poster Presentation]</td></tr></table>en_GB
dc.date.available2011-10-27T10:38:32Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:38:32Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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