J Public Health (2013) 21:3–13 DOI 10.1007/s10389-012-0531-x
ORIGINAL ARTICLE
Categories of errors and error frequencies as identified by nurses: results of a cross-sectional study in German nursing homes and hospitals Monika Habermann & Ronja Foraita & Henning Cramer
Received: 18 January 2012 / Accepted: 11 July 2012 / Published online: 31 July 2012 # Springer-Verlag 2012
Abstract Aim Knowledge about nurses’ error perception is crucial for establishing a sustainable risk management. This paper presents categories and frequencies of errors as identified by nurses. The cross-sectional study results provide further knowledge for professional and organizational development. Subject and methods Data from 1,100 German nurses working in 30 hospitals and 46 nursing homes were collected using a self-administered questionnaire. This paper firstly presents results from a content analysis of nurses’ descriptions of errors and, secondly, results on frequencies of predefined nursing errors (closed-ended, ordinal frequency estimation). Thirdly, it compares the answers of hospital nurses with those of nurses employed in nursing homes and finally it compares answers of participant groups defined by sex or migration background. Results In the open-ended section, errors described by 60.5 % of the participants concerned medical diagnosis/therapy. 20.7 % had experienced errors in hands-on care, while errors in communication with patients were noted by 3.7 %. In contrast, when offering predefined activities in the questionnaire’s closed-ended part, indicated frequencies of errors M. Habermann (*) Centre for Nursing Research and Counselling, Hochschule Bremen, University of Applied Sciences, Neustadtswall 30, 28199 Bremen, Germany e-mail:
[email protected] R. Foraita BIPS - Institute for Epidemiology and Prevention Research, University of Bremen, Achterstrasse 30, 28359 Bremen, Germany H. Cramer Luenener Strasse 61, 59379 Selm, Germany
stressed issues of hands-on care and documentation. Significant differences exist between participants from both settings regarding direct care and relationship building. Sex and migration background were related to frequency estimations. Conclusions Findings point to shortened professional perspectives in the debates on risk and safety. This might lower nurses’ compliance in risk management systems. The influence of health professionals’ sex and migration background on their error perception needs further exploration. Field specific approaches for error prevention are needed. Keywords Hospitals . Nursing . Nursing error . Nursing homes . Patient safety . Resident safety
Background Error reports from all types of health care settings show that errors severely affect the outcome of services, adding to human suffering and raising the costs of health care (Institute of Medicine 2000, 2001; Benner et al. 2006; Sanghera et al. 2007). Nurses rendering hands-on care are acting close to patients in hospitals and residents in nursing homes. Their monitoring and managing of patient care is crucial for the identification and prevention of errors (Mitchell 2002). Evidence-based knowledge about nurses’ perception of errors is therefore essential for the purpose of establishing a sustainable risk management. From a professional perspective, the issue of nursing errors signifies the profession’s “negative knowledge”. Such knowledge represents the reverse side of nurses’ knowing and enacting professional standards (Habermann 2007). Incorporating this knowledge in training and practice contributes to the development of the profession. Research focusing on errors in health care settings has included nurses in several aspects. An in-depth literature
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review on nursing errors showed, however, that nurses’ perception and categories of errors have very rarely been on the research agenda. An early study by Arndt (1994a, b) broached the issue of the ethical competence and judgement of nurses when dealing with errors. Meurier et al. (1997, 1998) advanced the subject of nurses’ errors in a study focusing on categories of errors and monitoring cases of errors as viewed by nurses. The authors provided a definition of nursing errors which has also been used in the study presented in this article. They regarded an error as “any wrongful decision, omission or action for which the nurse felt responsible and that had adverse or potentially adverse consequences for the patient and that would have been judged wrong by knowledgeable peers at the time it occurred” (Meurier et al. 1997, p. 113). Benner et al. (2006) added substance to these few studies by developing categories of nursing errors specifically relating to nurses’ work and professional tasks in order to support the work of the National Council of State Boards of Nursing in the USA. Not only nurses’ error perceptions and categories are underrepresented in research. Knowledge about error frequencies in nurses’ work is also limited. The predominant part of research results relates to medication errors, which are, probably as a result of this dominant research focus, regarded as the most common errors. This idea is, for instance, supported by Balas et al. (2004, 2006) who analysed error logbook entries recorded by hospital nurses who revealed that over 50 % of all reported errors were medication-related. Contrary to that, the results of a study by Inoue and Koizumi (2004) conducted in six hospitals, and including a broad scope of nursing activities, indicate that errors occur most frequently in the context of prevention such as safeguarding against falls. Additionally, in an early study using a retrospective review of resident incident reports, Gurwitz et al. (1994) found that only 4.6 % of all events reported in a large long-term care facility were related to drugs. As Cook et al. (2004) point out, numbers or proportions of errors depending on self-reports of health personnel should be treated cautiously. The expectations of nurses that errors occur most often with medication-related tasks may potentially block their view on other error-prone aspects of their work. In that case, non-medication errors have a tendency to remain unrecognised, and therefore underreported. In a similar instance, Benner et al. (2006) point to the fact that, as the wide scope of nurses’ work and professional responsibilities remains often unrecognized in health care, the attention to errors and their investigation may also be limited to medical assistance. When summing up the results of research endeavours so far, there is a manifest lack of understanding of nurses’ conceptions and categories of errors in different fields as well as a lack of knowledge about how frequent errors occur, taking various and broad aspects of nursing practice into account.
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This lack of knowledge is important since endeavours to close safety gaps in health care settings must rely on the commitment and support of those working at the sharp end and, being the largest group, this refers to the nurses. The first representative study focusing on these issues has therefore been conducted in Germany from 2007 to 2010 by the Hochschule Bremen’s Centre for Nursing Research and Counselling (ZePB). Considering alarming reports on frequent errors in the German health care system (Board and for the Concerted Action in Health Care 2003) and on severe quality deficits in nursing care (Medical Review Board of the Statutory Health Insurance Funds 2001; 2007) putting the topic of nursing errors on both the research and political agenda, the study aimed to explore the error perception of German nurses in two different settings of inpatient care: hospitals and nursing homes. The research questions of the part of the study presented in this article were: – – – –
What does count for an error in the perception of nurses working in the German health care system? How frequently do different kinds of errors happen estimated by nurses? Do study participants working in hospitals differ in their perceptions from those working in nursing homes? Are sex and migration background related to error perception and estimation of frequencies?
In order to answer these questions, this paper (1) presents results of a content analysis of error categories as presented by nurses’ answers to an open-ended question on an error the nurses had experienced; (2) presents results on frequencies of errors in nursing fields (closed-ended, ordinal frequency estimation); (3) compares the replies from the hospital nurses with the answers of the nurses employed in nursing homes; and (4) presents results of correlation analyses between some characteristics of the respondents (sex, migration background) and their identification of categories and frequencies of errors.
Methods Design A cross-sectional research design has been applied, based on a self-administered questionnaire. The project’s workflow is presented in Fig. 1. Sampling strategies Nursing education in Germany consists of three distinct 3year training courses: general nursing, paediatric nursing, and elderly care. The first two programmes teach primarily acute and hospital nursing while the third course instructs in
J Public Health (2013) 21:3–13 Fig. 1 Project workflow
5 Qualitative explorational study n=18
Laws , quality reports , general data ,…
Questionnaire „ structural characteristics “ Hospital
Structural characteristics Hospitals n=30
Analysis of interviews
Questionnaire Questionnaire for nurses
Nursing ursing home
Hospital
Literature analysis
Nursing home
Mailed to institutions n=76
Mailed to participants n=3905
Structural characteristics Nursing homes n=46
Questionnaires returned Hospitals n=745
Questionnaires returned Nursing homes n=403
Results
long-term home and nursing home care. Another statelicensed programme of nursing is based on 1–2 years of training preparing these nurses for tasks in direct care and limited medical tasks. This educational level is roughly comparable to that of licensed practical nurses in the US, enrolled nurses in Australia/New Zealand, or state enrolled nurses in the UK. The term of “licensed practical nurses” (LPNs) will therefore be used in this article. The sample consists of nursing personnel employed at 30 hospitals and 46 nursing homes with more than 50 beds/ places in north-west Germany. The institutions were randomly chosen after stratifying according to national numbers on size and ownership, and replaced by another randomly chosen institution in the same strata in case the original institution refused to participate. In the participating nursing homes, questionnaires were allocated to registered nurses (RNs; 3 years of training) as well as LPNs. Participants had to be more than only marginally employed (i.e., earned more than 400 EUR/month and in consequence had a certain minimum of work hours per week) and had to work in direct resident care. LPNs were included in nursing homes because they have basic professional knowledge and have to perform nursing tasks in direct care. They support registered nurses who in general comprise only little more than 50 % of the total nursing staff in German nursing homes due to legal requirements. In hospitals, only RNs employed at least half-time (approx. 20 h per week) in direct patient care were surveyed. LPNs in hospitals were excluded since they constitute only a small number (5 % percent of the staff, Federal Statistical Office of Germany 2011a) and are seldom involved in direct nursing care. The number of persons surveyed depended on the hospital’s size. In institutions with up to 150 beds, all persons meeting inclusion criteria received a questionnaire.
In hospitals with up to 300 beds, a randomly selected sample of 50 nurses was chosen, in hospitals with more than 300 beds the random sample comprised 100 nurses. Questionnaires were sent to the institutions by the researchers and handed out to participants by gatekeepers like the head of staff council or members of staff associations. Participants sent the questionnaires directly back to an institute that was commissioned to record and analyse the data.1 This institute was introduced into the study to exclude members of the primary study group from data administration and especially from data analysis in order to secure independence of analysis and anonymization of organizational and institutional data. A sample size of 1,800 per setting was chosen based on calculations assuming a response rate of 40 %. This parameter was met, with 3,905 nurses (1,920 from nursing homes and 1,985 from hospitals) receiving a questionnaire. Data collection Data collection was based on a self-administered questionnaire. Its development included an extensive literature review and an explorative qualitative preparatory study (semistructured interviews including 18 nurses working at nursing homes and hospitals). The latter was undertaken to add to and to refine the dimensions and items derived from international literature analysis to fit the German context. Questionnaire development was also supported by a panel of experts from health care and research institutions, and experts representing insurances and agencies responsible for quality control. 1 The external institute was included into the preparation of this article in person of Ronja Foraita.
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In eight sections of the questionnaire, participants were questioned on nursing errors and on demographics and their professional background (e.g., age, sex, kind of training or years of nursing experience). Each section of the questionnaire pursued different objections, therefore the number of items asked and the design of each section differed in order to meet its particular requirements. The first section explored nurses’ categories of errors in an open-ended way. Participants were asked to describe an error: “First please describe an error that you made yourself or observed in your work field and that spontaneously comes to your mind.” In a following section, nurses were asked to rate the frequency of errors made in predefined everyday nursing activities by assigning one of four ordinal frequency values (“never”, “less than once a month”, “at least once a month”, “at least once a week”). In correspondence to the definition of nursing error as a “decision, omission or action … that had adverse or potentially adverse consequences for the patient and that would have been judged wrong by knowledgeable peers” (Meurier et al. 1997, p. 113), we applied a broad scope of errors, ranging from wrongful or missing wound treatment or oral hygiene to addressing patients or their relatives in an abrasive manner. The questionnaire was pre-tested in one hospital and one nursing home and no changes were deemed necessary. In addition, nursing directors or administrative managers were asked to answer a structured questionnaire about the organizational features of their institutions. Data were collected from September 2008 to May 2009. Ethical considerations Data were collected anonymously as far as individuals were concerned. Questionnaires had to be linked to an institution in order to relate participants’ answers to organizational data, but institutions did not receive feedback on the answers given by their employees. Participants were provided with a detailed information letter which they received together with the questionnaire. That letter told participants to fill out the questionnaire at home and to send it back directly to the institute that was commissioned to record and analyse the data.
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nursing organization, nursing documentation, participation in medical diagnosis and therapy, coordination of care— cooperation with other professions. This model has been developed by Krohwinkel (1993) and has found broad acceptance in guiding the development of research and practice in Germany. The categories are considered to be comprehensive and exclusive as well. They represent the multifaceted field of nursing work, and every activity (and every possible error) carried out by nurses belongs to one of these categories. In order to gain a more detailed picture, the “medical diagnosis/therapy” category was further differentiated into “medication errors” and “non-medication errors”. In addition to these specifications, the following categories were implemented due to their specific importance for the nursing profession or due to frequently reported quality problems in nursing: “communication with patient/resident”, “communication without patient/resident”, “hygiene”, “violence/contempt” and “self-injury”. In the case of participants describing more than one error (n090), we included all descriptions into the analysis. (Proportions listed in Table 1 therefore do not sum up to exactly 100 %.) We controlled for different proportions of multiple descriptions with regard to sector (hospital or nursing home), sex and migration background, using Chi squared statistics. Frequencies of each nursing practice error were calculated separately for hospitals and nursing homes and compared between both settings. Since responses from the same hospital or nursing home may be more similar than responses from different facilities, logistic mixed models (LMM) were used to account for within-cluster correlations. Ordinal logistic mixed models (OLMM) were applied to investigate the impact of institution, sex and migration (participants who either are born outside of Germany, have at least one parent who was born outside of Germany, or do not speak German at home) on frequencies of errors. Additionally, these analyses were adjusted or stratified by institution Table 1 Sample characteristics All institutions n01.100
Data analysis A well-established model of the tasks and responsibilities of nursing was used as a categorial framework when comparing the answers to the open-ended question in order to find out what kinds of incidents (in which parts of nurses’ work and responsibilities) are regarded as an “error” by respondents. All answers were allocated by two members of the research team into one of the following categories as defined by the model: direct nursing care (“hands-on nursing”),
Female Age59 years Migration background
85.7 0.1 19.6 22.0 36.0 21.0 1.3 11.5
% % % % % % % %
Hospitals n0724
86.4 0.1 16.3 23.8 38.6 20.6 0.6 9.1
% % % % % % % %
Nursing homes n0376 84.5 0.0 25.9 18.4 31.2 21.9 2.7 16.0
% % % % % % % %
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(hospital/nursing home). P-values 0,4.
Categories of error
Nursing organization
NH nursing homes; H hospitals; ref. reference category
Categories of errors in two health care settings
Other
+H
+H
+H
+H
NH + H NH H NH + H
Error described N (%)
OR (95 % CI)
126 102 228 25 35 60 30 37 67 173 493 666 1 19
(33.5) (14.1) (20.7) (6.7) (4.8) (5.5) (8.0) (5.1) (6.1) (46.0) (68.1) (60.5) (0.3) (2.6)
(ref.) 0.32 (0.23–0.45) – (ref.) 0.71 (0.37–1.39) – (ref.) 0.62 (0.03–15.74) – (ref.) 2.42 (1.76–3.32) – (ref.) 10.11 (1.34–76.23)
20 48 66 114
(1.8) (12.8) (9.1) (10.4)
– (ref.) 0.68 (0.43–1.01) –
p-value
