AUGUST 2001, VOL 74, NO 2 R I.: V I I< W S

It E SE A RC I I HE V I EiVS

UNDERSTANDING THE NATURE OF ERRORS IN NURSING: USING A MODEL TO ANAL P E CRITICAL INCI- DENT REPORTS OF ERRORS WHICH HAD RESULTED IN AN ADVERSE OR POTENTIALLY ADVERSE EVENT C E Mruriel- Journal of Advanced Nursing Vol32 (July 2000)

P tunities for potential clinical error. Although every nurse has made errors, professional mistakes usually are a source of shame and embarrassment. Typically, errors are kept quiet for fear of repercus- sion or loss of professional status. Due to the emotional component of committing an error, the person making an error may not view objectively the chain of events that led to an adverse event. Although a great deal of personal learning may occur when one makes a mis- take, this knowledge usually is not communicated to others. This research provides a utilization model to communicate and explore adverse events.

unteer RNs wrote about a critical error incident that led to an adverse outcome. After the inci- dents were documented, five par- ticipants were interviewed for fur- ther data generation. Reason’s Organization Accident Model was used to elicit information about the chain of events leading to the disclosed incident.

Model. Reason’s Organization Accident Model lists five factors to consider when examining an adverse event. These five factors are latent failures, conditions of work, active failures, barriers/

202-207

erioperative nursing is clinical- ly complex with many oppor-

Sample. For this study, 20 vol-

defenses, and adverse events. Both active and latent failures contribute to accidents. Active failures are unsafe acts committed by people at the site of occurrence that have immediate consequences. Active failures in an OR setting could include administering the wrong medication or operating on the wrong surgical site. Latent failures occur from fallible decisions made by people with indirect involve- ment, such as management team members. Examples of latent fail- ures are inadequate communica- tion systems, poor planning, heavy workload, inadequate training and supervision, or equipment disre- pair. These latent failures may lie dormant, but in emergencies or other crises, they may precipitate active failures.

Case study. This research arti- cle provided an in-depth analysis of only one documented example of an adverse event. The event focused on a woman hospitalized after overdosing on tranquilizers and alcohol. This patient was left unattended and jumped out of a window, thus sustaining fractures of the pelvis and lower extremi- ties. This event occurred in the United Kingdom and, therefore, the training and leveling of nurs- ing staff members differed from US requirements. The analysis, however, did identify a number of preexisting conditions that con- tributed to this adverse event. Error-producing conditions included inadequate staffing, shortage of experienced staff members, lack of window blocks, poor design of the ward (ie, not conducive to observation), and excess nurse caseload. Further, management, communication, policies, and training all were noted as latent failures. Back- ground factors (eg, workload,

supervision, communication, equipment, knowledge/ ability) were conditions of work factors defined in Reason’s model. The factor of bamers/ defenses was defined as inade- quate but was not addressed in any depth.

Discussion. This model could be implemented in the periopera- tive arena to explore adverse events. Adverse events are unex- pected Occurrences involving death or a serious physical or psycholog- ical injury. Nurses and managers involved with accreditation are aware of the important task of evaluating and preventing adverse events and may find this article useful. It may have been more use- ful to explore the commonalties of all 20 critical incidents rather than an in-depth case study of only one. This research did provide the read- er with system-wide error produc- ing examples, rather than blaming the individual thought to be re- sponsible for the error.

MICHELLE BYRNE RN, MS, PnD, CNOR

NURSINC RESEARCH COMMITTEE

ANALYSIS OF CHARGES AND COMPLICATIONS OF PERMANENT PACEMAKER IMPLANTATION IN THE CARDIAC CATHETERIZATION LABORATORY VERSUS THE OPERATING ROOM K H Yamamura et a1 Pacing & Clinical Electrophysiology Vol22 (December 1999) 1820-1 824

erioperative nursing has expanded well beyond the tra- P ditional walls of an OR suite.

During the past two decades, the trend toward implanting perma- nent pacemakers in cardiac catheterization laboratories

257 AORN JOURNAL