Nursing, Medical Errors and the Health Care System:
What's Gone Wrong? Can it be Fixed?

Recent news articles, building off a highly publicized series in the Chicago Tribune, have focused on nurses as the source of many, although not most, of the reported medical error-related deaths or injuries in this country. Errors gleaned from national and Illinois records, and explored in the series, included "honest" mistakes by competent nurses and errors caused by drug-addicted nurses, aided and abetted by what appears to be a failure of disciplinary systems for nurses in Illinois and surrounding states.

There are several questions to consider in sorting out the whys and wherefores and possible solutions to these errors.

Why do "honest" mistakes happen?

"The Chicago Tribune series began with the headlines that nurses make errors, but I think it is more accurate to say that the lack of nurses contributes to the error rate," says Dr. Patricia L. Starck, dean of the UT-Houston School of Nursing. "In fact, nurses catch a lot of potential errors before they occur," Dr. Starck says.

Texas has a nursing shortage, Dr. Starck says.

"We need 40,000 more registered nurses working than we have right now to be at the national average of nurse per population. Hospitals need not only to recruit, but retain nurses instead of the continual cycle of hiring, downsizing to save money, discovering that they actually need the R.N.s, then trying to re-recruit them after they have found work in another field," she advises.

In addition, changes in nursing education over the last decade have resulted in 70 percent of nursing graduates getting a two-year degree rather than a four-year baccalaureate degree, Dr. Starck says.

"You can't apply knowledge you don't have. The four-year graduates have two more years of schooling. And that is important because knowledge in the health care field is growing so rapidly," she states.

Many of the associate degree nurses are seeking to upgrade their education and should be supported to do so, she says.

Some state boards of nursing, Texas included, says Dr. Starck, have a "blame and punish" focus which is not conducive to correcting systems that contribute to errors. Errors have been endemic in the health care system for a long time, according to information on the American Medical Association's patient safety web site, says Dr. James Turley, vice chairman of the Department of Health Informatics at the UT-Houston School of Allied Health Sciences.

"However, we used to have enough `float' (nurse staffing hadn't been cut to the bone) in the system that there was redundancy and most of the errors were caught. Clearly, the issue is that we have cut costs to a point in the health care system that it is affecting patient safety," he says. "Another issue is that the amount and availability of information needed to care for people is escalating beyond an individual's ability to handle it."

If nurses generally aren't the culprits in incidents of "nurse error," then who or what is?

"Whenever there is an error, especially one that harms a patient, the initial reaction of health care professionals and the public is to blame the person most closely related in time or space. In the case of medication errors, this is usually the nurse, since nurses administer medications," says Dr. Eric Thomas, assistant professor of internal medicine at the UT-Houston Medical School and author of four recent papers on medical errors and their impact on health care.

"In other industries, this is called focusing on the `sharp end', which is very shortsighted," says Dr. Thomas, "By doing this, we are only seeing a very small part of the problem."

Most medical errors, says Dr. Thomas, have numerous contributing factors such as overwork, understaffing, bad handwriting, incorrect or incomplete patient information, and look-alike or sound-alike drugs. "It is these system errors we should be focusing on. If you fire a nurse who made an error and don't change the system that contributed to the error, the next nurse will make the same or a similar mistake," he cautions.

Medication names, colors and shapes seem to be designed for confusion, says Dr. Turley. "The name of a medication no longer uniquely identifies it. With our push to generics, the pharmacological name may have multiple commercial names and then, if it becomes available over the counter, another name or names may be put on it."

In addition, there is no standard as to what pills' colors or shapes signify.

"Each manufacturer has a different color/shape combination," says Dr. Turley. "As long as a medication is protected under patent, it's fairly easy to identify it by shape and color, but once it becomes generic and is made by multiple manufacturers, it can be sold in a variety of colors and shapes. The system is generating confusion."

The transmission of a hospitalized patient's medical information from one health care professional to another also leaves plenty of room for error. Mary Pat Rapp, president of the National Conference of Gerontological Nurse Practitioners, believes emerging technology can be helpful through comprehensive use of electronic medical records.

Under the current system, says Rapp, who is also an assistant professor at the UT-Houston School of Nursing, when a patient is transferred from a hospital to a rehabilitation center, for example:

• the physician writes the discharge orders on an order form in the hospital;
  
  
• the hospital nurse transcribes the orders to a transfer sheet;
  
  
• the new facility's nurse transcribes the order to a medication administration record and sometimes to a telephone order; and
  
  
• the pharmacist transcribes it to an electronic record.

"That's four people to transcribe one order with the possibility for at least one mistake by each of them," says Rapp.

How, then, can the system be fixed?

Dr. Lucian Leape, an adjunct professor of health policy at Harvard University's School of Public Health, looked at the possible steps in Can We Make Health Care Safe?, his contribution to Reducing Medical Errors and Improving Patient Safety, a report from the National Coalition of Health Care and the Institute for Healthcare Improvement. Dr. Leape identified the following steps needed to improve the system:

• There must be a substantial and sustained effort at all levels of the health care system to reduce the risk of error.
  
  
• Leadership must redefine accountability, managing for patient safety just as they manage for efficiency and profit maximization.
  
  
• Still, health care organizations must hold workers accountable. If a doctor or nurse has injured a patient through egregious misconduct, neglect or criminal activity, he or she must be punished. But if such a person had a prior history of reckless and unsafe behavior, why has he or she been permitted to continue working?

Regulators and accrediting bodies should be accountable to the public and the professions to set and enforce safety standards, says Dr. Leape. There is a need for safe practice rules in health care, he advises, including standards for maximum working hours, work loads, staffing ratios, expertise, safe medication practices and many others.

Those same regulators and accrediting organizations need to shift their focus from individuals to organizations when errors occur, requiring a thorough investigation of the underlying systems failures and a plan that addresses those failures, concludes Dr. Leape.

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©2006 Texas Medical Center

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