An error by any other name.

Recent reports from the Institute of Medicine and other sources have shown that far too many avoidable medical errors occur; other research has shown a strong association between patient outcomes and characteristics of nursing staff. The authors of this paper present findings from multimethod research conducted over three years in 29 small rural hospitals in nine Western states. They examined the organizational processes used to recognize medical errors and assign responsibility for them to resolve patient-safety issues. The research comprises seven substudies that used surveys, questionnaires, interviews, and case studies to gather data from nurses, physicians, administrators, pharmacists, and other health care workers.Generally, participants responded positively to questions about an institution's receptivity to communicating about errors and agreed on the most common kinds of errors that occur. But other data suggest that providers' understanding of patient safety is heavily conditioned by preconceived notions of what constitutes an error and of professional roles. Participants' analyses of case studies showed that they don't agree on what constitutes error or what kinds of events should be reported. And in one substudy, even when there was overwhelming agreement among participants (97%) that an error had occurred, only 64% would disclose the error to the patient affected. Physicians, administrators, and nurses tended to perceive patient safety as primarily a nursing responsibility. Only 22% of respondents to one survey said that physicians, nurses, pharmacists, and administrators should share responsibility equally for patient safety. The research was not designed to answer specific questions about the recruitment and retention of nurses, but the data collected suggest that institutional processes used to identify errors, assign responsibility for them, and resolve patient-safety issues may have unintended, harmful effects on nurse recruitment and retention. The authors propose that "a systems approach to patient safety" be adopted, one in which responsibility for safety is shared by all members of the health care team.