For 20 years, nursing has been rated as the most trusted profession in national Gallup polls. Even so, nurses make mistakes from time to time.
A new report by professional liability insurer Coverys offers insight on the kinds of errors that lead to medical malpractice claims. The carrier found that patient monitoring, medications, patient falls and pressure injuries were the cause of more than three quarters of claims.
Susan L. Montminy, director of risk management, said Coverys decided to take a deep dive into data relating to the involvement of nurses in malpractice claims because the profession has endured tumult in the past few years: Burnout caused by the challenges of coping with a pandemic, disrupted education and training, staffing shortages, tight budgets and a cultural shift including an increase in the use of travel nurses on temporary assignments.
The report includes recommendations on how to avoid nursing errors.
“We are not trying to point fingers,” she said. “These are signals. This is a warning that alerts them to vulnerabilities. These are hypotheses. It’s really a call to action.”
The analysis found that nurses are relatively a small part of the malpractice problem. While nurses make up 56% of the health care workforce, they were involved in just 18% of claims, which accounted for 26% of paid indemnity, according to the report. Physicians, in contrast, were involved in 50% of claims.
Montminy, a registered nurse herself, said the close relationship that nurses have with patients may be a reason they are less likely than other health professionals to be involved in allegations of improper care. “They are the face of care,” she said.
Physicians, in contrast, are more distant figures. Often they are viewed as the “captain of the ship,” consequently they are more likely to be blamed when something goes wrong.
The high esteem given to nurses is reflected in Gallup’s annual Honesty and Ethics survey. In the latest poll taken last December nurses were rated high or very high by 81% of respondents. That’s far above doctors who came in second with 67% and grade-school teachers at 64%. Gallup said nurses have been on top of the survey for 20 years.
But when mistakes are made, the results can be fatal.
Coverys evaluated 4,634 events that led to malpractice claims that were closed from 2018 through 2021. The researchers identified 850 specific events where nurses were directly involved in the care that resulted in the alleged medical error.
Death was the result of 37% of those events. An additional 10% resulted in major disability, such as blindness or paraplegia.
The top causes:
- Patient monitoring was involved in 45% of events leading to malpractice claims, with death resulting in those cases 49% of the time.
- The administration and management of medications accounted for 18% of the malpractice events. Death was the result of 39% of the alleged errors.
- Patient falls accounted for 14% of the malpractice events, with 41% of those falls resulting in death.
- Pressure injuries were the source of 10% of the malpractice claims, with 56% of those cases occurring at long-term or extended-care settings. Death resulted in 52% of cases.
Coverys said the data shows that comprehensive information is crucial to avoid errors in caregiving. Poor outcomes often result when nurses lack details about a patient’s medical history. Comorbidities, such as dementia or heart disease, were present in 80% of cases involving patient monitoring, patient falls and pressure industries, and 75% of cases involving medications.
Vigilance is necessary. Nursing requires multitasking and good work flows. Distractions and emergencies combined with a heavy workload can lead to errors.
Nurses must be encouraged to speak up when they have concerns, or when they know they’ve made a mistake. Patient safety is improved when teams don’t fear retribution or blame for reporting errors.
Effective teamwork is also vital. Nurses are the eyes and ears of health care. Their collective watchfulness is essential to effective patient monitoring.
Coverys said to improve patient monitoring, health care professionals can use monitoring algorithms to help nurses evaluate signs of a worsening conditions. Montminy explained that scoring systems can be used to send alerts when vital signs such as temperature or blood pressure deteriorate.These should be coupled with a reliable chain-of-command policy that provides specific steps to resolve conflicts.
Technology can be helpful to reduce medication errors. Most errors occur in inpatient settings, the report says. Medication dispensing cabinets should be reconfigured to require input of at least the first five letters of a drug name when ordering medications. Staff should be educated to optimize the use of safety features that are embedded in electronic health records and medical equipment. Also, health facilities should establish “no-interruption” policies for nurses while they administer medications.
To prevent falls, health care facilities should use a standardized fall risk assessment tool to identify patients who are at high risk on admission. Nurses should not place too much trust in equipment. Devices such as bedrails and restraints that are used to prevent falls can also increase the risk of harm from a fall because patients can become caught or entangled in the devices.
Pressure injuries can be avoided if patients undergo a head-to-toe skin assessment on admission and at repeated intervals during the stay. All nursing staff should be educated on avoiding pressure injuries.
The report says most of the events that led to malpractice claims involving nurses had one or more risk issue; a failure to function as a cohesive clinical team, miscommunication between the physician and the nurse, cultural or organizational vulnerabilities, a failure to ensure a safe environment through adequate staffing or workplace design and distractions that cause a lack of situational awareness.
To make nursing safer requires acknowledging that vulnerabilities exist,” said Maryann Small, senior director of risk management and analytics for Coverys, in a video attached to the report. “And where there are vulnerabilities, there are opportunities for improvement.”
The report can be downloaded here.
About the photo: Nurses work in the emergency department at NYC Health + Hospitals Metropolitan, Wednesday, May 27, 2020, in New York. The pandemic has led to staffing shortages, training interruptions and burnout for nurses, increasing the chance of errors that endanger patient safety, Coverys says. (AP Photo/John Minchillo)