Recovery from medical errors: the critical care nursing safety net.
BACKGROUND
Safety initiatives have primarily focused on physicians despite the fact that nurses provide the majority of direct inpatient care. Patient surveillance and preventing errors from harming patients represent essential nursing responsibilities but have received relatively little study.


METHODS
The study was conducted between July 2003 and July 2004 in a 10-bed academic coronary care unit. Direct observation of nursing care and solicited and institutional incident reports were used to find potential incidents. Two physician reviewers rated incidents as to the presence, preventability, and potential severity of harm of errors and associated factors.


RESULTS
Overall data were collected for 147 days, including 150 hours of direct observation. One hundred forty-two recovered medical errors were found, including 61% (86/142) during direct observations. Most errors (69%; 98/142) were intercepted before reaching the patients. Errors that reached patients included 13% that were mitigated before resulting in harm and 18% that were ameliorated before more severe harm could occur.


CONCLUSIONS
Protecting patients from the potentially dangerous consequences of medical errors is one of the many ways critical care nurses improve patient safety. Interventions designed to increase the ability of nurses to recover and promptly report errors have the potential to improve patient outcomes.
Rothschild
Jeffrey M
JM
Harvard Medical School, Boston, USA. jrothschild@partners.org
Hurley
Ann C
AC
Landrigan
Christopher P
CP
Cronin
John W
JW
Martell-Waldrop
Kristina
K
Foskett
Cathy
C
Burdick
Elisabeth
E
Czeisler
Charles A
CA
Bates
David W
DW
D000046:Academic Medical Centers; D001900:Boston; D002983:Clinical Competence; D003299:Cooperative Behavior; D003325:Coronary Care Units / Q000592:standards*; D003422:Critical Care / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D033183:Interdisciplinary Communication; D019300:Medical Errors / Q000145:classification / Q000517:prevention & control* / Q000706:statistics & numerical data; D008991:Monitoring, Physiologic; D024802:Nurse's Role; D009731:Nursing Audit; D009738:Nursing Service, Hospital / Q000592:standards*; D019370:Observation; D010348:Patient Care Team / Q000592:standards; D017751:Safety Management; D013597:Systems Analysis