task; act by concentrating and performing the task; and review their actions to check for the desired result. This self‐checking takes only a few seconds but greatly reduces the probability of making an error. Double checking one's own work also helps to prevent these errors. Nurses learn to check, re‐check, and check a third time before administering medications. Determining that the right drug in the right dose is being given by the right route, at the right time, and to the right patient involves checking the medication label against the medication order or medication administration record three times. In addition, two unique patient identifiers are verified prior to administering the medication. Health care facilities typically define which two patient identifiers are to be used, most often full name and date of birth. High risk medications, such as insulin, may require independent verification by another nurse. The independence of this double‐check helps to prevent skill‐based errors.
Rule‐Based Performance
In rule‐based performance, the clinician applies a learned rule to an appropriate situation. The delivery of health care is largely based on rules, often called protocols. Rules may be learned in nursing school or through life experience, clinical experience, or continuing education. Errors may occur when functioning in a rule‐based performance mode. Leaders need to track data on staff compliance with rule‐based clinical performance and continually look for ways to improve practice. Errors occur in three ways: using the wrong rule; misapplying the rule; and disregarding the rule.
Sometimes, clinicians use the wrong rule. They may have been taught or somehow learned the wrong response for a situation. For example, Donna graduated many years ago and learned to treat patients for hypoglycemia if the glucose was 60 mg/dl or less. If Donna has not kept current with more recent diabetes and hypoglycemia guidelines, she will fail to treat a patient with a glucose of 70. The solution to this type of error is to educate clinicians with the right rule.
A rule‐based error also occurs if the clinician misapplies the rule. The nurse may know the right response but select another response instead. For example, Donna's patient has a blood sugar of 64 mg/dl. Donna knows it needs to be treated. Rather than rely on her memory, she quickly consults the hypoglycemia algorithm—an excellent safety practice. The algorithm indicates treatment with 15 g of glucose. Donna misreads the algorithm and gives 30 g of carbohydrates instead. This could over‐correct the low blood sugar, causing the blood sugar to spike and creating another patient safety event. This type of error may be prevented by pausing and thinking or reviewing a second time.
Rule‐based performance errors may also be caused by disregarding the rule, as when the clinician knows the rule but chooses not to follow it. For example, Donna's patient has a hypoglycemic event and she treats it appropriately. Donna knows that she should recheck her patient's glucose level 15 to 30 minutes after treating hypoglycemia. She sees that the patient is alert and oriented and looks fine. Donna tells the patient to put on her call light if she runs into any problems and does not recheck the blood sugar. Non‐compliance with rules can be prevented in several ways. First, Donna needs to understand the risks involved in not following the rules. In addition, organizations need to reduce the burden or difficulty of following the rules. Nurse leaders need to consider if there are adequate numbers of bedside glucose monitors so that a glucose recheck can be easily accomplished. They need to examine staffing to ensure it is enough to allow time for the glucose recheck. Last, Donna may need to be coached by her manager to make better decisions. If this is a repeated behavior, Donna will need to be counseled and disciplined by a nurse manager.
Critical Thinking 4.1
Donna, RN is caring for Mrs. Miller. Nursing Assistant Carly tells Donna that Mrs. Miller's routine bedside glucometer reading was 63 mg/dL. Donna appropriately treats Mrs. Miller with 15 g of glucose and asks Carly to recheck the blood sugar for the patient in room 532 in a half hour or so. Forty‐five minutes later, Carly tells Donna that she checked Mrs. Martin's blood sugar and it was 97 mg/dL. The nurse enters Mrs. Miller's room an hour later and finds her pale, diaphoretic, and confused.
Answer these questions:
1 What communication errors occurred in this scenario?
2 How did Carly confuse Mrs. Miller and Mrs. Martin?
3 What has happened to Mrs. Miller?
4 How could Donna have prevented the confusion and miscommunication?
Knowledge‐Based Performance
In knowledge‐based performance, a clinician is solving problems in a new and unfamiliar situation. Clinicians may try to figure out how to perform based on what they already know, using trial and error, or even guessing at the solution. This is very dangerous. For example, Cindy is an experienced nurse who has been working in critical care for 15 years. When she arrives on her shift, her patient is receiving Continuous Renal Replacement Therapy. Cindy has not previously managed this therapy and is not familiar with the supplies and fluids used. Rather than proceeding independently, Cindy needs to stop and consider requesting a safer assignment. Alternatively, Cindy may work with an expert and consult a written resource such as an evidence‐based protocol while providing care.
Nurses and nurse leaders need to understand skill, rule, and knowledge‐based performance when investigating errors. Nurses who have been involved in an error should focus on how they made the decision they did. Did they develop a short cut or work‐around to save time? Did they fail to do a double check of their own work? Did they proceed even though they were not familiar with the procedure? Each type of error requires a different solution. The three performance modes are critical to keep in mind when designing error prevention strategies.
Root Cause Analyses
Root cause analysis (RCA) is an error analysis tool used in health care to investigate serious adverse events. TJC has mandated the use of RCAs to analyze sentinel events since 1997. RCAs identify underlying problems that increase the likelihood of errors rather than focusing on mistakes made by individuals. An RCA uses a systems approach to identify both active and latent errors. The goal of an RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events.
RCAs begin with data collection and reconstruction of the event through record review and participant interviews. An interprofessional team then analyzes the sequence of events leading to the error, with two main goals: identify how the event occurred through identification of active errors; and identify why the event occurred through systematic identification and analysis of latent errors (AHRQ, 2018a, 2018b). Action plans are developed, implemented, and evaluated based on RCA findings.
Nurse leaders striving for high reliability must facilitate RCA investigations into how and why errors occur. These investigations make errors visible, encourage learning from events, and help prevent errors in the future. Direct care nurse involvement in RCAs is critical to their success. As part of the RCA investigation, nurses need to be comfortable while recounting the actions they took and the rationale for their actions. In addition, direct care nurses are crucial for the development of action plans to help mitigate future risk.
Creating a Culture of High Reliability
This is a critical role for the CNO and other nurse leaders within an organization. Patients are counting on health care organizations for help and do not expect to be injured as part of that care. Nurse leaders must take many actions to achieve this culture. It begins with strategic planning.
Strategic Planning
Strategic
