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Nursing Errors. By: Kristy Clark and Dawn Simon. What is a nursing error?. A mistake that is made by a nurse that: Can affect the outcome of something Causes an adverse effect Is a result of poor judgment Is potentially irreversible

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Nursing errors l.jpg

Nursing Errors

By: Kristy Clark and

Dawn Simon


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What is a nursing error?

  • A mistake that is made by a nurse that:

    • Can affect the outcome of something

    • Causes an adverse effect

    • Is a result of poor judgment

    • Is potentially irreversible

      Anoosheh, M., Ahmadi, F., Faghihzadeh, S., & Vaismoradi, M. (2008). Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran. International Nursing Review, 55(3), 289.


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Ohio Law Regarding Nursing Errors

  • According to the Ohio Board of Nursing, all licensed nurses should report errors.

  • Unfortunately, Ohio law doesn’t mandate that you report a medical error, therefore many go unreported.

  • It’s an RN’s ethical obligation to report his/her errors as well as other nurse’s errors that are witnessed.

    Ohio Board of Nursing (n.d.). Chapter 4723-4 standards of practice relative to registered nurse or licensed practical nurse. Retrieved from http://codes.ohio.gov/oac/4723-4.

    Karlsen, K., Hendrix, T., & O'Malley, M. (2009). Medical error reporting in America: a changing landscape. Quality Management in Health Care, 18(1), 59-70.


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Types of Nursing Errors

  • Medication administration:

    • Given at wrong time, wrong patient

    • Lack of documentation of administration and given more than once

    • Not given at all

    • Given at incorrect site i.e. IM injection in a subcutaneous site.

    • Calculation error

    • Illegible penmanship and failure to obtain clarification

      Austin, S. (2008). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.

      Bohomol, E., Ramos, L., & D'Innocenzo, M. (2009).

      Medication errors in an intensive care unit. Journal

      of Advanced Nursing, 65(6), 1263.


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Types of Nursing Errors (cont.’d)

  • Patient neglect

  • Ignore what the patient is saying

  • Perform duties beyond an RN’s scope of license

  • Failure to report and monitor for deterioration

  • Communicating ineffectively with family and colleagues during transfer of care

  • Careless documentation- inaccurate, not in a timely manner, and/or failure to document completely

    Austin, S. (2008 March). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.


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Impact of Nursing Errors on Patients

  • Patient dies

  • Patients condition worsens

  • Patient develops permanent disability

  • Lawsuit


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Discipline R/T Nursing Errors

  • Not all errors lead to punishment

    • R/T not being reported

    • No harm to patient

  • Loss of RN license

  • Suspension of RN license

  • Incarceration

  • Humiliation R/T your name, reason for losing/getting license revoked and reason for the punishment being published on the www.nursing.ohio.gov


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Causes of Nursing Errors

  • Personal life interfering with professional life

  • To stressed to think clearly

  • Take on to large of an assignment

  • Show up to work impaired R/T alcohol or drug use

  • Understaffed units

  • Under qualified nurses

  • Long shift hours

  • Inadequate time available for proper nursing care

  • Failure to follow requirements for continuing education


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How Errors are Corrected

  • Tell the patient about the error if coherent

  • Notify patients family if patient is incoherent

  • Report and properly document error in a timely manner

  • Do everything possible to prevent adverse effects of error on patient


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How to Report an Error That You Witness

  • Complete a complaint form located on www.nursing.ohio.gov under the forms tab

  • Send completed form to the Ohio Board of Nursing via website listed

  • Report to nursing supervisor

  • If it was you that made an error, fill out an incident report via hospital protocol


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Nurses at risk

  • New RN’s with limited experience

  • RN’s who cannot say no

  • RN’s who work on a unit that’s understaffed


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Are Medical Errors an Issue?

  • It’s suggested that the leading cause of death in the U.S. is preventable adverse events in the hospitals.

  • The most common medical errors are medication errors

    • Affect at least 1.5 million people each year

    • Cost the health care system between $77 and $177 billion annually

  • More than 42% participants in a study said they or someone that they knew had experienced a medical error.

  • Out of all healthcare professionals, RN’s have been responsible for the most medical error related patient deaths.

    • Due to nurses spending the most time with patients

      Anoosheh, M., Ahmadi, F., Faghihzadeh, S., & Vaismoradi, M. (2008). Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran. International Nursing Review, 55(3), 288-295.

      Reinburg, Steven. (2009, April 27). Medication errors could be cut: experts. US News and World Report. Retrieved from http://www.usnews.com/health/managing-your-healthcare/healthcare/articles/2009/04/27/medication-errors-could-be-cut-experts.html


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Ways to Prevent Nursing Errors

  • Ask another RN to double check your medication calculations

  • Call physicians for order clarifications

  • Double check pharmacy

  • Only do what you can handle

  • Ask questions when necessary, use available references

  • Ask for clarification with orders that are not legible


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Ways to Prevent Nursing Errors (Cont.’d)

  • Use “five rights” of medication administration

    • Right patient

    • Right medication

    • Right dose

    • Right time

    • Right route

      Austin, S. (2008). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.


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Ways to Prevent Nursing Errors (Cont.’d)

  • When transferring care of patient or report patient’s condition use SBAR

    • Situation

    • Background

    • Assessment

    • Recommendation

      Austin, S. (2008). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.


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Nursing Process

  • “Most legal actions brought against nurses arise because a patient or a patient advocate claims that the nurse breached a standard of care and that the breach resulted in harm to the patient” (Austin, S. 2008).

  • Nursing assessment

  • Nursing diagnosis

  • Planning

  • Implementation

  • Evaluation

    Austin, S. (2008 March). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.


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Conclusion

  • Nursing errors can be prevented, which is why we chose this topic to present to you today

  • Just one error could lead to permanent loss of a nursing license making all the late nighters, stress, and four years or more of nursing school completely pointless


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References

  • Anoosheh, M., Ahmadi, F., Faghihzadeh, S., & Vaismoradi, M. (2008). Causes and management of nursing practice errors: a questionnaire survey of hospital nurses in Iran. International Nursing Review, 55(3), 288-295.

  • Austin, S. (2008). Seven legal tips for safe nursing practice. Nursing 2008, 38(3), 34-39.

  • Bohomol, E., Ramos, L., & D'Innocenzo, M. (2009). Medication errors in an intensive care unit. Journal of Advanced Nursing, 65(6), 1259-1267.


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References (cont.’d)

  • Karlsen, K., Hendrix, T., & O'Malley, M. (2009). Medical error reporting in America: a

    changing landscape. Quality Management in Health Care, 18(1), 59-70.

  • Ohio Board of Nursing (n.d.). Chapter 4723-4 standards of practice relative to registered nurse or licensed practical nurse. Retrieved from http://codes.ohio.gov/oac/4723-4.

  • Reinburg, Steven. (2009, April 27). Medication errors could be cut: experts. US News and World

    Report. Retrieved from http://www.usnews.com/

    health/managing-your healthcare/healthcare

    /articles/2009/04/27/medication-errors-could-be-cut-experts.html.





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3.) Jessica has been an RN at a local hospital for 1 week and she takes on an assignment that is to much for her to handle. Who should she talk to about this?


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4.) What is the website that displays the names of the nurses who’ve lost his/her license or had the license suspended?


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5.) Name two ways to prevent a nursing error. nurses who’ve lost his/her license or had the license suspended?


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6.) Why are RN’s considered the most responsible out of all healthcare professionals for medical error related deaths?


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7.) How does a nursing error affect a patient? all healthcare professionals for medical error related deaths?




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10.) Name three ways a nurse can do a nursing error involving medication administration.




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13.) Not listening to a patient does not mean you are committing an medical error. After all, nurses are busy and don’t always have time to listen to every complaint.

True or False


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14.) What is the nursing process? committing an medical error. After all, nurses are busy and don’t always have time to listen to every complaint.




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17.) Why is SBAR important? a nursing error?



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19.) You should not admit to a patient when you make a mistake. If you do, they may lose trust in you.

True or False


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20.) If a nurse forgets to document a blood pressure from the 11:00 vital check, it is okay because vitals are checked again at 3:00 so it’s just one time that day you forgot.

True or False





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24.) When is SBAR used? medication errors.


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25.) If a nurse receives an order from a doctor and doesn’t understand one or two words, should the nurse still do what she does understand of the order?


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26.) Why should nurses report an error? doesn’t understand one or two words, should the nurse still do what she does understand of the order?


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27.) How do you report an error that you witness? doesn’t understand one or two words, should the nurse still do what she does understand of the order?




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