6.4.1 General findings.
The findings revealed that errors are common in the delivery of care and often affect patients adversely, but they are not always reported to the management. Nurses are also emotionally affected by their error and they feel the need for support in the aftermath of their error. If the error has le d to an adverse event, their emotional distress was greater. However, this may not be fully appreciated by the senior staff and a significant proportion of nurses felt dissatisfied after discussing the error with senior staff. The findings also indicate that nurses were willing to accept responsibility for their error and make constructive changes in their practice. Thus the potential for learning fi*om errors is there.
6.4.2 Types of errors.
When using the nursing process, nurses commonly make errors during the assessment/planning of care and nursing intervention stages, and to a smaller extent in the evaluation of care. Failures of communication are also important sources of errors. These findings support the Health Service Commissioner's (1987) concerns about nursing staff apparent difficulties in using the nursing process effectively and the quality of communication in health care delivery. In fact, in his conclusions, the Health Service Commissioner also made allusions of the fact that inability to use the nursing process correctly may be responsible for a "catalogue of errors" in nursing practice.
The findings also indicate that most of the errors which occurred during the process of care and in communication were the result of slips and lapses, although mistakes too play an important part. According to Reason (1990) slips and lapses are monitoring failures and occur because of a lack of timely attentional check. They are unintended acts. Mistakes, on the other hand, occur because of lack of knowledge or misinterpretation of a situation. They are errors of intention. A variety of factors such as work overload, stress, fatigue and interpersonal relations may cause slips and lapses. Therefore, the high occurrence of slips and lapses might suggest that these factors may be present in the nurses' working environment and may be affecting their performance. These have important implications in error-prevention strategies. In nursing, correct delivery of care is often contingent on the nurses remembering to do so. But this may be unreasonable to expect on a busy ward with staff shortages; the attention of the nurse may be divided between many tasks. Errors and failures may be inevitable in these situations. Reason has suggested that a system approach should be used to deal with errors such as slips, lapses and mistakes rather than an individual approach.
Chapter 6: Types o f nursing errors and their perceived causes
6.4.3 Perceived causes of errors.
The findings suggest that nurses perceived that many factors may be involved in the causation of errors. The most common reported causes of errors were stressful atmosphere, job overload, lack of knowledge or experience and inadequate supervision and support from senior staff. From these findings, it could be suggested that the climate in which the nurse has to work may be becoming more stressful and demanding, particularly in line of the rapid changes in the NHS and the market approach to health care. In fact, the Audit Commission (1996) reported a 16 % increase in emergency admissions, the brunt of this increased workload falling heavily on the nurses. In fact, work overload and stressful atmosphere are particularly perceived to be important causes of errors by nurses in this study. These may be creating working conditions that predispose to a variety of active failures (Reason, 1990).
6.4.4. Reporting of nursing errors.
There is evidence in this study that the nurses were reluctant to discuss their error to the senior staff. Yet, the majority felt the need to discuss their error with someone, presumably because of the stress associated with making a clinical error. The implications of not discussing the error with the appropriate personnel could affect patient care. For instance, since not all errors were reported to senior staff, they may not be fully aware of the "safety health" of their unit or the system's contribution to these errors. As a result, appropriate preventative measures may not be taken, and certain types of error-producing conditions may perpetuate in the system. Although the nurses were more willing to discuss their errors with the doctors, the doctors were still informed only in a small proportion of cases. This may deny the patients of any medical intervention or investigation that may be required as a result of the error. Patients and their relatives were also inadequately informed about mistakes that may have occurred in their care. This could lead to a lack of trust in the health care professions. It has also been found
that patients are more likely to sue for negligence when the they have not been given adequate information about mistakes in their care (Vincent, 1994).
6.4.5 Responses to errors.
In most cases of error, the nurse became emotionally distressed. Giving safe care to patients tend to be an overriding concern for nurses (Hibberd and Norris, 1992). Two types of emotional responses were prominent- internal and external responses. In internal responses, the nurse feels angry at herselfliimself, guilty and inadequate. There is evidence that these type of reactions are associated with taking responsibility for the error. What this may mean is that when a nurse takes responsibility for an error, she/he may initially react negatively towards herself/himself for having made the error in the first place, but subsequently take measures to ensure that similar errors are not repeated. Those nurses who make external responses (i.e. angry at others , fearful of repercussions) are more likely to adopt defensive changes in practice in terms of becoming less confident and more anxious in one's work or not reporting their errors. If the lack of confidence and increased anxiety are not recognised and dealt with appropriately in the aftermath of an error, they may affect the nurses' self-confidence and inhibit learning. There is also a danger that those nurses are more likely to make another error when being in this frame of mind.
Making an error may affect one's image of being competent (Arndt, 1994) and senior staff need to respond sensitively. After an error, nurses felt the need for support and most of them approached their colleagues for it, but few went to their managers. Indeed, Arndt (1994) argues that when an error is made, it is "important for staff to be reassured of their professional qualities". It is likely that the traditional approach of disciplining/admonishing nurses in all cases of error
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Chapter 6: Types o f nursing errors and their perceived causes
some staff from seeking support or from divulging their error, which could have negative consequences for their practice.
6.4.6 Changes in practice.
The potential for nurses to leam from their errors are there. The majority of nurses admitted to making some changes to their practice as a result of their error. Making constructive changes in practice may promote the delivery of safer care and also help to increase the general standard of care. The study suggests several factors are associated with making changes in practice. Accepting responsibility for the error are shown to be prerequisites for making constructive changes in practice, and only nurses who have personally made the error tend to show this response. It is therefore important to encourage nurses to accept responsibility for their error and to think objectively about how to ensure that future errors are minimised. In fact, those nurses who accepted responsibility for their errors also reported to make plans to ensure that they do not make a mistake again. This is in line with the professional ethos of the nurses: to be responsible and accountable for one's actions and to maintain one's level of clinical competence. The findings also show that those staff who tend not to divulge their error were unlikely to plan a course of action to deal with the after effects of the error. These staff were also found to be concerned about possible repercussions. It is possible that this type of defensive and unsafe behaviour may be the result of perceiving senior staff as insensitive and unsupportive, hence not trusting the senior staff to understand their predicament and treat them fairly.
The perception of causes of errors as well as the circumstances leading to the error were also associated with changes in practice. Potentially changeable factors such as lack of knowledge/experience and work overload were more likely to lead to reported constructive changes in practice than more internal causes such as faulty judgement. But this will be further investigated in chapters
8 and 10 as causal perception of an event are known to influence the type of reactions to that event (Kelley and Michaela, 1980).