Iranian Nurses Concerns Regarding Error Disclosure: A Qualitative Study

Transcription

1 World Applied Sciences Journal 17 (11): , 2012 ISSN IDOSI Publications, 2012 Iranian Nurses Concerns Regarding Error Disclosure: A Qualitative Study Fatemeh Hashemi, Alireza Nikbakht Nasrabadi and Fariba Asghari 1 Nursing and Midwifery College, Shiraz University of Medical Sciences, Shiraz, Iran 2 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran 3 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran Abstract: Background Revealing an error to a patient is an important ethical consideration The present study was designed to explore nurses perceived concerns regarding error disclosure Method Information obtained from 80 experienced nurses regarding their error disclosure using focused group discussion method Data were then analyzed using inductive content analysis method Results patient s reactions, managers responses and job insecurities were obtained results Conclusion Health care systems need to address nurses concerns in order to prepare a safe ground for error disclosure Nurses should have access to planned education about nursing errors and the benefits of error disclosure Also rules on error disclosure should be developed to be implemented by all health organizations Key words: Nursing errors Patient safety Error disclosure INTRODUCTION important ethical principle-omissions that can therefore diminish patient safety The present study was conducted Nursing errors have always been a serious yet to clarify and explore nurses concerns about disclosing inevitable threat to patients safety and can cause high nursing errors in Iran rates of mortality and can increase the cost of treatment [1, 2] In Iran the incidence of these errors is unlikely to be Method: This qualitative study was conducted to explore lower than the developed countries [3] nurses concerns regarding error disclosure by Preventing medical errors is desirable, but if an error documenting the experiences of nurses at two large occurs, ways of dealing with that is important [4] university hospitals in Iran Data were collected with a Disclosing medical errors to patients and their families is focus group discussion method, which allowed considered an essential activity It is important not only participants an opportunity for open discussion of to disclose errors to patients and their families, but also to various issues, especially potentially vulnerable issues apologize and involve in the process of post-care [9] Sixteen focus group meetings were held, treatment sincerely [5] each attended by expert head nurses and staff nurses In spite of the numerous benefits and ethical The number of participants in each group was 5 and the basis of error disclosure and despite patients needs, sessions lasted between 60 and 90 min [9-10] Expert head clinicians-especially nurses-may be reluctant to disclose nurses and staff nurses from different university hospital errors, in order to protect themselves from penalties and wards were invited to participate and sessions lasted until administrative rules [5-6] Despite the frequency of heath data saturation [10-11] care errors, only a small percentage of them are disclosed Before the research began, the protocol was to patients and most of the time this small percentage is approved by the research ethics committees of Tehran insufficient [7] University of Medical Sciences and Shiraz University of According to the findings of earlier studies, Medical Sciences Two researchers led all groups A basic numerous obstacles including health care providers scenario of a nursing error was provided from a review of concerns and fears [8-9], lead to noncompliance of this the literature [9] The scenario was reviewed and adapted Corresponding Author: Fatemeh Hashemi, Faculty Member of Pediatric Nursing Group, Nursing and Midwifery College, Shiraz University of Medical Sciences, Shiraz, Iran Tel: , Fax:

2 World Appl Sci J, 17 (11): , 2012 by the research team and a number of expert hospital legal follow-up and complaints by patients and their nurses and qualified researchers Based on feedback from families to legal authorities In some cases patients might an initial focus group session to ensure transparency and exaggerate errors to obtain compensation (blood money) comprehension of the material, the scenario was adapted and some were abusive Participants reported several as appropriate All subsequent group discussions were reasons for deciding not to inform patients about health based on the same scenario [9-11] care errors, eg, the patient s inability to understand, All recorded sessions were transcribed to facilitate lack of culture of cooperation, patients intolerance and data analysis and coding To explore the main themes and culture of abuse by some patients For example, one of the categories related to nurses concerns about nursing error nurses reported the following experience: In our ward a disclosure, inductive content analysis was used blind patient fell out of his bed and suffered a fracture Content analysis is a systematic technique for analyzing His fracture was treated and he was discharged from the written texts to condense and organize the data The key hospital Three months later he died in his home from feature of this process is that many words of the text other causes But his family said he died because of his related to specific subject are classified into much smaller fall from the bed and consequent fracture in the hospital but more comprehensive categories [10-11] The nurse responsible for the patient still has to appear The emerged classification and categories were in court and they got about $ as blood money reviewed by research team and approved by experienced from that nurse qualitative data analyzer This process was repeated several times until the researchers were certain that they Concerns about Administrators Reactions: This theme had captured all the commonalties and differences [10] contained two subclasses: limited administrator tolerance and overstatement of errors and lack of administrator RESULTS support In connection with administrators limited tolerance and magnification of errors, the issues raised Forty-six nurses and 34 head nurses participated in were that they disregarded good work and focused only this study They worked in different general and on errors, angered easily, magnified mistakes and specialized wards of the two universities humiliated staff for their mistakes For example, one of the After data analysis, three main categories of concerns participant s experiences illustrated an administrator s related to nursing error disclosure to patients and their inappropriate reaction and lack of support as follows: families were identified: patients negative reactions, On my shift at 9 pm an enema was performed for the administrators reactions and job insecurities patient and he was rushed to the bathroom He fell and suffered a mild skull fracture I immediately came over to Concerns about Patients Negative Reactions the patient and picked him up I checked his This Theme Had Three Subclasses: change in the consciousness level and called his doctor Then a skull quality of trust and the nurse-patient relationship, CT scan was performed and was followed up until the patients distress and patients complaints to legal next morning Then we reported the incident to the head authorities Change in the quality of trust and the nurse But he was very angry with me He wrote to the relationship between patients and nurses were nursing office that Mrs X on a certain shift did not emphasized by all the participants The experience of one attend to the patient He fell from his bed and is now of the participants illustrated one patient s anxiety, having problems This report was added to my file anger and loss of trust after being informed about a staff Then they investigated me about it Can you understand error: The patient s antibiotic was discontinued but his what an adverse impact that had on me? Should I be drug card wasn t removed I didn't notice and I expected to report such cases if it happens again? mistakenly injected the antibiotic in the patient The patient was informed, but he lost his patience and Concerns about Job Insecurities: Regarding concerns shouted I apologized, but he told the head nurse not to about job sanctions, the issues participants mentioned allow me to care for him were constantly facing threats, fear of layoff, With regard to concerns about patients complaints uncertainties about job security, reputational damage from to legal authorities and abuse by some patients, a number a written reprimand being included in the staff member s of participants mentioned issues such as excessive anger, file and relocation to a different ward regardless of the 1522

3 World Appl Sci J, 17 (11): , 2012 nurse s personal preference Statements made by one of the capability of nurses to provide health care services the participants and supported by most of the nurses [21]Other studies, like the present one, suggest that fear reflected concerns about occupational sanctions of administrators negative reactions [5,22-23] and reactions disproportionate to the severity of the We ourselves saw how harshly they behaved error are reasons for failure to disclose errors [24-25] with someone who reported his error in honesty Further studies are needed to explore the reasons for They added a written reprimand to his file administrators excessive negative reactions to nursing As punishment, they changed his work place and errors even his official position The main factors that contribute to administrators reactions appear to be of insufficient knowledge about the DISCUSSION benefits of disclosing errors Enhancing administrators knowledge regarding these issues can be helpful in Health care providers due to negative effects of error disclosing errors and increasing patient safety [5] disclosure prefer to under-report errors because those The participants were fearful of error disclosure who accept the risk of error disclosure may face negative because of their professional prestige and dignity and reactions from their colleagues, authorities and patients loss of respect and trust among their colleagues [12-15] Participants in earlier studies have cited previous Other studies have also found that fear of losing negative experiences with administrators, physicians and professional prestige and dignity and fear of being blamed colleagues as a deterrent and continuing concern Like the by their colleagues [5, 17, 26] and physicians [24-27] were present study, other reports have shown that fear of obstacles to disclosure Colleagues culture of naming, damaging health care providers relationship with patients shaming and blaming is the most important barrier and loss of patients confidence in health care providers in error disclosure and increase secrecy [4-5] and health care services are obstacles to error disclosure Moreover, apprehension about legal follow-up and job [5, 9] Other studies have reported a rise in complaints by threats and economic losses discouraged participants in patients in other countries as well as in Iran [16] They this study like other studies from disclosing or reporting also reported fear of patients negative reactions, errors [5, 9] In order to overcome these obstacles, legal follow-up and litigation as an additional obstacle to it is essential to regard nursing errors as multifactorial error disclosure and error reporting [17, 14-15, 18] events When errors occur it is ultimately more effective Despite these concerns, nondisclosure of nursing to identify and eliminate the causes of the error than to errors does not appear to be an appropriate or viable identify and punish individuals [4,28] solution As other studies have shown, patients complain According to our findings, most nurses believe that in order to obtain more information about their treatment disclosing an error to the patient is one of the patient s and even more because an error was under-reported [19] rights, but many concerns deter them from error Another motivation is the assumption that health care disclosure Among the various reasons for poor error providers have not been honest and truthful and have disclosure are legal responsibility, the patient s anxiety concealed an error [20] It seems that there is an and distress, a potential decline in professional and social assumption of a strong trust-based relationship between credibility and trust and fears of job loss Nevertheless, health care providers and patients [9] Therefore, ways of none of these reasons justifies the failure to disclose an communicating, quality of the dialogue and ways of error [29] Organizations should try to eliminate these sharing the errors with patients may affect their barriers and develop and implement regulations for error acceptation and may reduce their annoyance [15] disclosure [30] Appropriate error disclosure can thus be followed by patient satisfaction, confidence and positive emotional CONCLUSION reactions [5] Participants in this study mentioned concerns about In order to increase error disclosure and patient administrators limited tolerance for errors and the lack of safety it is necessary that health policy makers try to support from administrators as issues that lead nurses to recognize and eliminate the obstacles to error disclosure avoid disclosing errors to patients Some studies have Also administrators should be trained in strategies to suggested that better administrative support enhances eliminate or minimize staff concerns and as well replace 1523

4 World Appl Sci J, 17 (11): , 2012 the culture of blaming and punishing with the culture of 10 Eto, S and H Kyngas, 2008 safety And moreover, clear regulations and guidelines The Qualitative Content Analysis Process J Adv should be developed to ensure best practice in error Nurs, 62(1): disclosure as a policy to support patients rights 11 Krippendorff, KH, 2003 Content analysis: an introduction to its methodology 2nd ed London: ACKNOWLEDGEMENTS Sage 12 Thurman, AE, 2001 Institutional responses to hereby we would like to thank Shiraz University of medical mistakes: ethical and legal perspectives Medical Sciences and Tehran University of Medical Kennedy Inst Ethics J, 11(2): Sciences through grant no and Blumental, D, 1994 Making medical errors into respectively for their financial support And also would medical treasures JAMA, 272: like to thanks K Shashok (Author AID in the Eastern 14 Hobgood, C, JH Tamayo-Saver, A Elms, et al, Mediterranean) and Ms Sara Medvari for improving the 2005 Parental preferences for error disclosure, use of English in the manuscript Also many thanks for all reporting and legal action after medical the nurses in Shiraz and Tehran Universities of Medical error in the care of their children Pediatrics, Sciences for their sincere participation 116(6): Schwappach, DL and CM Koeck, 2004 REFERENCES What makes an error unacceptable? A factorial survey on the disclosure of medical errors Int J 1 Chard, R, 2010 How perioperative nurses define, Qual Health Care, 16(4): attribute causes of and react to intraoperative 16 Jafarian, A, A Parsapoor, A Hajtarkhani, et al 2009 nursing errors AORN Journal, 91(1): A survey on the complaints registered in Medical 2 Howe, JP, 2010 Nursing Error Lawyer, Council Organization of Tehran J Med Ethics Nursing Error Lawyer History Med, 2(2): com/medical %20 Malpractice %20-%20 Nursing 17 Loren, DJ, EJ Klein, J Garbutt, et al, 2008 %20Error ham (accessed on 2010) Medical Error Disclosure among Pediatricians: 3 Joolaaee, S, F Hajibabaee, H Peyravi, et al, 2010 choosing carefully what we might say to parents The incidence and report rate of medication errors in Arch Pediatr Adolesc Med, 162(10): Iran J Med Ethics History Med, 3(1): Mello, MM, DM Studdert and TA Brennan, Hashemi, F, 2008 Ethical response to nursing error The new medical malpractice crisis N Engl J Med, J Med Ethics History Med, 1(4): (23): Wolf, ZR and RG Hughes, 2008 Error reporting and 19 Kachalia, A, KG Shojania, TP Hofer, et al, 2003 disclosure In: R Hughes, eds Patient Safety and Does full disclosure of medical errors effect Quality: An Evidence-Based Hand Book for Nurses malpractice liability? The injury is still out Jt Comm Rock Ville: AHRQ Publication, pp: 1-47 J Qual Saf, 29(10): Mason, DJ, 2005 To forgive, divine: it s time to drop 20 Hickson, GB, EW Clayton, PB Githens, et al 1992 the veil of secrecy about disclosing errors Am J Factors that prompted families to file medical Nurs, 105(12): 11 malpractice claims following prenatal injuries 7 Banja, JD, 2008 Problematic medical errors and JAMA 1992 Mar 11, 267(10): their implications for disclosure HEC Forum, 21 Adib-Hajbaghery, M and E Aminoroayaei Yamini, 20(3): Nurses perception of professional support 8 ACEP, 2010 Disclosure of Medical Errors Feyz, Journal of Kashan University of Medical Ann Emerg Med, 56(1): 80 Sciences, 14(2): Fein, S, L Hilborne, M Kagawa-Singer, et al, Mayo, AM and D Duncan, 2004 Nurse perception A conceptual model for disclosure of medical errors of medication errors: What we need to know for In: K Henriksen, JB Battles and ES Marks, eds patient safety J Nurs Care Qual, 19(3): Advances in Patient Safety: From Research to 23 Blegen, MA, T Vaughn, G Pepper, et al, 2004 Implementation Rockville: Agency for Healthcare Patient and staff safety: voluntary reporting Amer J Research and Quality, pp: 2 Med Qual, 19(2):

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