Reduce Medical Errors through Education and Responsibility

Reporting and evaluating medical mistakes and near-misses can give critical care nurses insight on how to avoid common errors, Elizabeth A. Mattox explained in an afternoon session yesterday.

Mattox, who is currently president of the Mountain to Sound Chapter in Seattle, stated that no error is insignificant and each one can be useful in avoiding future mistakes. Medical errors account for 44,000 to 98,000 deaths per year, and the ICU is a particular danger zone.

"We have to start understanding that this is a very serious problem," Mattox said.

Communication and Disclosure

Open communication with patients and disclosure of errors can prevent future medical mistakes, according to Mattox. Disclosures should describe an error in a way that is meaningful to the patient. After admitting a mistake, a discussion should take place detailing a prevention plan, followed by an apology to the patient. Currently, less than 1 in 4 errors are disclosed.

"Reporting errors requires an environment of trust," said Mattox.

Current systems instruct nurses to complete a "write-up" of the error, which supports self-incrimination, commonly fails to examine root causes of an error and provides no feedback. Nurses are concerned about the consequences of disclosing minor errors but are eager to participate in disclosure discussions. Failure to disclose error contributes to moral distress, is an ethical violation, and guarantees that the mistake will be made again. Mattox promoted practice responsibility, which encompasses an educational institution, licensing and certifying bodies, and professional groups rather than individual responsibility, which targets the individual and focuses on blame.

Defining Error

"When we start talking about error we must have a common language. We must be able to talk about what happened in a way that makes sense to others," Mattox said.

Mattox differentiated between a mistake and a lapse, defining a mistake as a planned, intended action that fails to achieve an intended result. A mistake is often subtle, complex and difficult to understand and can occur during conscious problem-solving.

A slip or lapse is an intended action that does not proceed as planned and often occurs during an automatic, routine and familiar situation. Distraction, inattention, fatigue, emotion and environment are all factors that can cause a lapse. Because slips or lapses occur during routine situations, systems must be designed that do not rely on memory, vigilance or automatic tests that nurses can naturally adapt to and automate.

Mattox identified two theories regarding error discussion. The systems theory involves interactive, interrelated or interdependent components forming a unified, complex whole. This theory, often applied in high-reliability organizations, can create chronic unease and learned helplessness. The chisel theory, on the other hand, suggests that things happen for a reason. Components of this theory include the blunt end that sets up the "latent" conditions and the sharp end that is conventionally blamed for the error. However, more than 90% of error is not the fault of the sharp end. Nurses are identified as the sharp end and therefore have a unique ability to prevent and identify error dependent on skills, resources and environment.