Individual, practice, and system causes of errors in nursing: a taxonomy.
Practice errors by nurses can cause harm to patients, families, practitioners, systems, and the profession. Because the nursing errors reported to the State Boards of Nursing are typically serious, analyzing their data has great potential for developing new strategies to reduce dangerous errors. With the guiding rationale being identification of categories central to the nurse's role and function in healthcare delivery errors, 21 case studies of nursing errors from 9 State Boards of Nursing files were analyzed to develop a taxonomy of nursing errors. Eight categories of nursing errors representing a broad range of possible errors and contributive or causative factors were identified: lack of attentiveness; lack of agency/fiduciary concern; inappropriate judgment; lack of intervention on the patient's behalf; medication errors; lack of prevention; missed or mistaken MD/healthcare provider's orders; and documentation errors. Causes for the error, at the system and practice responsibility levels, were identified in each case. The categories, an assessment of causes of errors, and an examination of the remediation actions taken were the first steps in devising a taxonomy of nursing error, designed with prevention in mind. The authors discuss their work and present the taxonomy.
Benner
Patricia
P
School of Nursing, University of California-San Francisco, Box 0612, San Francisco, CA 94143, USA. benpat@itsa.ucsf.edu
Sheets
Vickie
V
Uris
Patricia
P
Malloch
Kathy
K
Schwed
Kathy
K
Jamison
Dwayne
D
D000368:Aged; D000369:Aged, 80 and over; D002965:Classification; D004647:Employee Discipline; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007600:Judgment; D008008:Licensure, Nursing; D008297:Male; D019300:Medical Errors / Q000145:classification* / Q000451:nursing* / Q000517:prevention & control; D008508:Medication Errors / Q000145:classification / Q000451:nursing / Q000517:prevention & control; D009740:Nursing Staff / Q000592:standards*; D010344:Patient Advocacy; D010865:Pilot Projects; D013597:Systems Analysis; D014481:United States