Research Briefs

Baccalaureate Nursing Students’ Accounts of Medical Mistakes Occurring in the Clinical Setting: Implications for Curricula Carey M. Noland, PhD

ABSTRACT Since the Institute of Medicine’s landmark report on medical mistakes, To Err Is Human, was published, considerable attention has been given to training medical professionals about medical mistakes. However, little research has been conducted to explore the experiences of nursing students with mistakes made during their clinical rotations. If nurse educators are to teach nursing students how to deal with mistakes appropriately, it is necessary to have a more complete understanding of the types of mistakes nursing students make during their training, how and if they communicate about their mistakes, and students’ perceptions of how prepared they were to address the mistakes. Greater knowledge in this area will help nurse educators better prepare nursing students to intercept and report mistakes. This article presents research results from three components of a larger qualitative research study that explored the socialization processes of nursing students in regard to medical mistakes. [J Nurs Educ. 2014;53(3, Suppl.):S34-S37.]

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edical mistakes are the “unanticipated negative consequence of a medical intervention” (Mizrahi, 1984, p. 135). It is widely accepted that the two root causes of medical mistakes are system error and human error. Nursing curricula and institutional instruction vary in the degree to which they address (implicitly and explicitly) medical mistakes, in particular, providing procedures to follow if one makes a mistake; teaching communication skills in mistake interception; talking to patients, patients’ families, and supervisors about mistakes and apologies; and dealing with the feelings they experience about making or witnessing a mistake. Nurses are also at risk of becoming a second victim to medical mistakes (Wu, 2000), especially when they feel traumatized by the event and personally responsible for the mistake (Jones & Treiber, 2012). Information about the medical mistakes that nursing students make and how they communicate with others about those mistakes will help nursing faculty develop curricula to provide nursing students with the necessary skills to intercept, report, and resolve mistakes.

Literature Review

Received: June 15, 2012 Accepted: October 1, 2013 Posted Online: February 11, 2014 Dr. Noland is Associate Professor, Communication Studies, Northeastern University, Boston, Massachusetts. The author has disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Carey M. Noland, PhD, Associate Professor, Communication Studies, 204 Lake Hall, Northeastern University, Boston, MA 02115; e-mail: [email protected]. doi:10.3928/01484834-20140211-04

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The Institute of Medicine (IOM) and The Joint Commission have recognized the pivotal role that nurses play in keeping patients safe and the importance of clear and concise communication (IOM, 2000, 2004; Joint Commission, 2011). Hohenhaus (2008) reported that nurses receive insufficient training for the skills necessary to actively recognize, report, and resolve medical mistakes, especially after a mistake has been made. Although approximately 65% of medical mistakes are never disclosed to patients (IOM, 2004), physicians often handle the situation without including nurses, regardless of who made the mistake (Shannon, Foglia, Hardy, & Gallagher, 2009). Research has indicated that newer nurses are more likely than experienced nurses to make mistakes. Henneman et al. (2010) studied the types of mistakes made by nursing students in a simulated environment and found that “100% of nursing student subjects committed errors...this should be cause for concern about patient safety” (p. 11). Although numerous studies are available about how nurses prevent, intercept, report, and communicate about mistakes (Hohenhaus, 2008; Krautscheid, 2008; Shannon et al., 2009; Stetina, Groves, & Pafford, 2005; Tjia et al., 2009; Westbrook, Woods, Rob, Dunsmuir, & Day, 2010; Woloshynowych, Davis, Brown, & Vincent, 2007), little research has focused on nursing students. Because it is important Copyright © SLACK Incorporated

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to understand the types of mistakes nursing students make and how they deal with mistakes, this research study asked nursing students the following questions: ● What kinds of mistakes do nursing students make during their baccalaureate nursing degree (BSN) educational experience, and how do nursing students communicate about the mistakes? ● What do nursing students think of their training regarding medical mistakes? ● How do nursing students feel about medical mistakes?

Method Participants

Study participants were students enrolled in either a 4-year (n = 2) or 5-year (n = 36) BSN program at universities in the northeastern United States. Students were recruited using snowball sampling tactics. A small group of nursing students known to the primary investigator were asked to contact other nursing students who qualified for the study and might be interested in participating. In turn, each recruit was asked to provide names and e-mail addresses of other potential participants. All of the students had completed at least one clinical rotation, and the majority of students (79%) were in their final year of school. At the time of their interview, approximately half of the participants(47.3%) had more than 2 years of experience in hospitals either as certified nursing assistants or as nursing students, and approximately 60% reported experience at three or more institutions. Data Collection

Data were acquired from single 45- to 90-minute qualitative face-to-face interviews. Interviews followed a semistructured protocol and were audiotaped and transcribed verbatim. The participants were asked to describe a memorable mistake that they had made (if they could not recall making a mistake, they were asked to recount a mistake that they had witnessed), describe how they felt about the mistake, and describe and evaluate their training regarding medical mistakes. The study was approved by the university’s institutional review board. Data Analysis

The three research questions constituted the framework of the analysis; the answers were evaluated using qualitative content analysis. Frequencies of the types of mistakes were calculated. Content analysis was used because it provided an objective and systematic description of the content of interviews from which inferences about the messages within the text could be made (Berelson, 1952). After transcribing and listening to the taped interviews, participants’ responses for each question were coded into categories. Each interview was coded line by line, and key words, phrases, patterns, and repetitions in responses were identified and corroborated by counting. Significant categories for the second and third research questions were developed on the basis of the interview content. A category was noted when there was (a) recurrence (similar meaning communicated but with different words), (b) repetition (reiteration of key words and phrases), and (c) forcefulness (indicated by vocal features such Journal of Nursing Education • Vol. 53, No. 3, Suppl., 2014

as inflection or volume that set off certain portions of an account from other portions) (Owen, 1984). Quotes that best embodied a participant’s feelings and beliefs for each question were highlighted and included in the final manuscript. The categories were verified with 20 of the participants, who supported the qualitative findings.

Results Research Question 1

The first research question asked participants, “What kinds of mistakes do nursing students make during their BSN educational experience, and how do nursing students communicate about the mistakes?” Although all of the participants reported a sentinel event that occurred in an institution during their training, 10 students (26%) said that they had never made a mistake or could not recall making a mistake. When asked to recall one specific example of a mistake, the remaining respondents reported a total of 30 medical mistakes that they had made. The mistakes were categorized as follows: 20%, mislabeled/mixed up name/forgot label; 3.5%, forgot to document (e.g., wrong dose of painkiller); 26%, administered incorrect medication (e.g., out-of-date medicine or wrong time); 20%, negligent (e.g., did not note patient discomfort such as pressure sore or incorrect position of item such as neck brace, bottle-fed baby rather than tube-fed, or ripped out tubing/lines); 27%, performed an unnecessary procedure (e.g., blood draw or electrocardiogram) on the wrong patient; and 3.5%, needlestick injury. When asked how they handled the mistake, 48.2% of the participants were able to correct the error and 51.8% were unable to fix the mistake; the majority (72.4%) of participants reported their mistake to the patient or their supervisor, depending on the severity of the mistake. Most of the participants thought that if the mistake was not serious, it did not need to be reported to their supervisor. For example, one participant drew two blood samples out of order and had to repeat the draw; she corrected the mistake and told the patient but not her supervisor. When asked how they communicated about the mistake, participants reported as follows: 8 (27.5%) fixed the mistake and disclosed it, 6 (20.6%) fixed the mistake and did not tell anyone, 11 (37.9%) could not fix the mistake and reported it, 2 (6.8%) could not fix the mistake and did not tell anyone, 1 (3.4%) was immediately corrected by the clinical instructor, and 1 (3.4%) mistake resulted in an emergency situation. Research Question 2

The second research question asked participants, “What do nursing students think of their training regarding medical mistakes?” When asked if they had any formal training on how to handle mistakes, 19 students said they had received formal training and 19 said they had received no training. Of those who indicated they had formal training, all but one said they had attended an orientation at the start of work that showed them how to document a mistake. Given typical new-employee training, it is not surprising that the focus was on procedural communication. Only one participant reported that she had actually been taught how she should behave (e.g., remain calm) and how to talk about the mistake with both her patient and supervisor. Of the participants who reported no formal training, most said that S35

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they had talked informally about making mistakes in a college class, talked to other nurses about mistakes, or considered Situation Background Assessment Recommendation (SBAR) communication as a type of training that could prevent mistakes. Research Question 3

The third research question asked participants, “How do nursing students feel about medical mistakes?” Most of the participants believed that mistakes happen to everyone (92%), that they are inevitable (92%), and that they were important learning opportunities (100%). The nursing students clearly believed that it was their job to catch mistakes that others made. They all believed nurses were an important part of the medical team and had a duty to be diligent when it came to noting mistakes. When asked to recount a memorable moment where they participated in or witnessed a mistake, many of the nursing students reported that experienced nurses “saved the day” when they recognized a mistake because of their knowledge. Participants thought that when experienced nurses prevented, interrupted, or rectified mistakes, it was due to overall proficiency. New nurses caught mistakes because of systems (e.g., automated medication dispensing system) or because they double-checked information. Although experienced nurses caught mistakes because of the knowledge and skills they developed with time, students were acutely aware of their need to double-check everything, and most stated they were confident that the system would catch most of their mistakes. Many students counted on themselves or others to catch things that “fall through the cracks.” Comments made by fifth-year students included: • So it’s good that everyone double-checks the system but usually I catch my own mistakes or even sometimes it’ll pop up and I’ll be like “Oh, that’s the wrong patient.” You have to like make sure you double-check everything. • We had a patient who was very allergic to all the cillins and was written an order for penicillin, and I wasn’t aware of the allergy, which was my mistake, and it is a pretty serious one.... Their allergies are listed right at the beginning of their medication book, and right at the end before I walked into the room—and it was an injection of this so it would have taken its effects much sooner than a pill—and I literally just saw it by the grace of god. I was about to give it.

The importance of double-checking for mistakes came across in each narrative; however, a tension emerged between the inevitability of mistakes and the faith the participants had in themselves and others to catch mistakes. Narratives showed that nursing students thought that providers inevitably made mistakes, and most of the participants thought that mistakes did not always get reported, even serious ones. Approximately 30% of participants did not report a mistake that they made, even though hospital risk-management policies required all mistakes to be reported, no matter how small, particularly for those in training. Few of the students felt prepared to handle the mistake. Almost all of the students described feelings of panic, dismay, uncertainty, and even anger and frustration when they realized they had made a mistake. A typical account by a fourth-year nursing student demonstrates these feelings: At first my heart dropped and I was like, “Oh, no, what’s going to happen?” And I quickly started thinking, “Oh, I hope

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there’s a medication that, like an antidote, reverses the effects of the drug.” Then I did feel a little silly because it clearly did say in the computer not to be given until noon. But then at the same time, it was frustrating that I was able to remove it from the Pyxis, because the Pyxis system knows that it was just given basically. So it shouldn’t have been allowed for me to take it out...but it was a common mistake, and I’m glad that I made it.

Not only did this student report feeling panic at administering a drug at the incorrect time and insecure because she was unsure of the outcome, she was upset that the Pyxis machine had dispensed the medication. This response confirms that even nursing students rely on systems to catch mistakes. Like many participants, the student was glad she made the mistake because she considered it an important learning opportunity. In addition to feelings of panic and frustration, participants worried about disclosing the mistake to their supervisor or the patient. One fifth-year student described the following incident: I picked up this one baby and out came the tube because it got caught on something, and I felt awful. I almost cried. I just didn’t want to approach the nurse, and I didn’t want to tell her I pulled out his tube.... Similarly, I pulled out a g-tube one time. Everything came out including the balloon that holds it in place...We get upset about stuff like this but sometimes it’s just beyond our control, and it happens to everyone. You know, mistakes do happen. There’s always something that you don’t see.

Again, most students expressed panic and great distress. Participants described most of their mistakes as “common” and “beyond their control,” noting that they learned from their mistakes. Not only did most of the participants report feeling terrible, most also reported that they were uncomfortable telling their nurse supervisor about the mistake, even though they believed making mistakes were necessary learning experiences. Many explicitly addressed the feelings around disclosing a mistake. As one fifth-year student noted: It’s hard owning up to a mistake and swallow your pride, but you quickly adapt since the hospital setting is much more critical than any other. Even the simplest mistake can result in the loss of a life.

Discussion Results indicate that nursing students make mistakes during training, supporting the findings of Henneman et al. (2010) about students’ mistakes in simulated environments. One significant finding that emerged was the idea that some mistakes, especially small mistakes, do not get reported. Participants stated that they were taught to report mistakes and tell someone, but they were not told how to do it; often, they did not report their mistakes that occurred during their training. This observation is especially interesting given that the participants recognized small mistakes could lead to big mistakes and to serious harm to patients. Therefore, it is important for instructors and institutions to encourage nursing students to report all mistakes. Nursing instructors need to think about how to conceptualize medical mistakes and teach students about mistakes. Should curricula contain the assumption that mistakes are inevitable or that they are preventable if nurses are careful, double-check themselves, have proper systems in place, are heroic, etc? Half of the participants reported they received no formal training on Copyright © SLACK Incorporated

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dealing with medical mistakes. Even fewer participants reported they received training on how to communicate about mistakes, how to behave when they made a mistake, and how they could resolve the emotional turmoil they felt. Whether this information is accurate is irrelevant. If the students received training either in their classes or through their institution, the fact that they could not readily recall the information provided in the lesson or training is telling. The nursing students clearly indicated that they felt responsible for mistakes, even when the mistake occurred because they followed the orders of their supervising nurse. These findings support second-victim research by Wu (2000) and Jones and Treiber (2012). As one of the students who was following orders said, “I should have double-checked. It’s my fault.” The narratives highlighted the fact that the nursing students were emotionally distraught about the mistakes that occurred and did not focus on the patient and patient care. If the students had received better training about how to handle their feelings and about what procedures to follow, both the students and their patients would have benefited. Training about mistakes should cover emotional as well as procedural information for nursing students to help them deal with the second-victim phenomenon. Finally, supervisors, professors, and preceptors could provide concrete suggestions on how to communicate when a mistake is made. Although innovative approaches to teaching communication skills to nurses have been discussed (Zavertnik, Huff, & Munro, 2010), specific information about teaching communication skills related to medical mistakes is scarce in the nursing literature. Many participants indicated that their instructors made comments such as, “You will never forget your first mistake,” or “You are only human,” which are vague references on how to handle mistakes. Few educators offered concrete suggestions or shared their own stories about mistakes, which could be valuable learning tools. In future research, it would be valuable to study the studentpreceptor/nurse supervisor relationship and the kind of interactions that take place in the event of a mistake. Due to the nature of the current study, only one side of the story (that of the nursing students) was reported. It is unclear how nursing students reported mistakes and potential mistakes (that later became mistakes) to their supervisors. For example, did they stress to their supervisor that they felt this was extremely important and needed immediate attention? Were they hesitant and unsure in their report and thus led their supervisor to believe the situation was not that serious? Observation of the dyadic relation-

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ship would be essential in answering these questions and overall could help to improve the communication about mistakes and potentially lessen the incidence of mistakes.

References Berelson, B. (1952). Content analysis in communication research. New York, NY: Free Press. Henneman, E.A., Roche, J.P., Fisher, D.L., Cunningham, H., Reilly, C.A., Nathanson, B.H., & Henneman, P.L. (2010). Error identification and recovery by student nurses using human patient simulation: Opportunity to improve patient safety. Applied Nursing Research, 23, 11-21. Hohenhaus, S.M. (2008). Emergency nursing and medical error—A survey of two states. Journal of Emergency Nursing, 34, 20-25. doi:10.1016/j. jen.2007.04.016 Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Joint Commission. (2011). Sentinel events. Updated January 3, 2011. Retrieved from http://www.jointcommission.org/assets/1/6/2011_CAMBHC_SE.pdf Jones, J.H., & Treiber, L.A. (2012). When nurses become the “second” victim. Nursing Forum, 47, 286-291. doi:10.1111/j.17446198.2012.00284.x Krautscheid, L. (2008). Improving communication among healthcare providers: preparing student nurses for practice. International Journal of Nursing Education Scholarship, 5, Article 40. doi:10.2202/1548923X.1647 Mizrahi, T. (1984). Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Social Science & Medicine, 19, 135-146. Owen, W.F. (1984). Interpretive themes in relational communication. Quarterly Journal of Speech, 70, 274-287. Shannon, S.E., Foglia, M.B., Hardy, M., & Gallagher, T.H. (2009). Disclosing errors to patients: Perspectives of registered nurses. Joint Commission Journal on Quality & Patient Safety, 35, 5-12. Stetina, P., Groves, M., & Pafford, L. (2005). Managing medication errors—A qualitative study. Medsurg Nursing, 14, 174-178. Tjia, J., Mazor, K.M., Field, T., Meterko, V., Spenard, A., & Gurwitz, J.H. (2009). Nurse-physician communication in the long-term care setting: Perceived barriers and impact on patient safety. Journal of Patient Safety, 5, 145-152. doi:10.1097/PTS.0b013e3181b53f9b Westbrook, J.I., Woods A., Rob, M.I., Dunsmuir W.T., & Day, R.O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170, 683690. doi:10.1001/archinternmed.2010.65 Woloshynowych, M., Davis, R., Brown, R., & Vincent, C. (2007). Communication patterns in a UK emergency department. Annals of Emergency Medicine, 50, 407-413. Wu, A.W. (2000). Medical error: The second victim. The doctor who makes the mistake needs help too. British Medical Journal, 320, 726-727. Zavertnik, J.E., Huff, T.A., & Munro, C.L. (2010). Innovative approach to teaching communication skills to nursing students. Journal of Nursing Education, 49, 65-71. doi:10.3928/01484834-20090918-06

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Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting: implications for curricula.

Since the Institute of Medicine's landmark report on medical mistakes, To Err Is Human, was published, considerable attention has been given to traini...
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