Individual, Practice, and System Causes of Errors in Nursing: A Taxonomy

Practice errors by nurses can cause harm to patients, families, practitioners, systems, and the profession. Because the nursing errors reported to the State Boards of Nursing are typically serious, analyzing their data has great potential for developing new strategies to reduce dangerous errors. Wit...

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Bibliographic Details
Published in:The Journal of nursing administration 2002-10, Vol.32 (10), p.509-523
Main Authors: Benner, Patricia, Sheets, Vickie, Uris, Patricia, Malloch, Kathy, Schwed, Kathy, Jamison, Dwayne
Format: Article
Language:English
Subjects:
Aged
Aged, 80 and over
Classification
Employee Discipline
Fatal Outcome
Female
Humans
Infant, Newborn
Judgment
Licensure, Nursing
Male
Medical Errors - classification
Medical Errors - nursing
Medical Errors - prevention & control
Medication Errors - classification
Medication Errors - nursing
Medication Errors - prevention & control
Nursing
Nursing Staff - standards
Patient Advocacy
Pilot Projects
Systems Analysis
United States
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Summary:Practice errors by nurses can cause harm to patients, families, practitioners, systems, and the profession. Because the nursing errors reported to the State Boards of Nursing are typically serious, analyzing their data has great potential for developing new strategies to reduce dangerous errors. With the guiding rationale being identification of categories central to the nurse's role and function in healthcare delivery errors, 21 case studies of nursing errors from 9 State Boards of Nursing files were analyzed to develop a taxonomy of nursing errors. Eight categories of nursing errors representing a broad range of possible errors and contributive or causative factors were identified: lack of attentiveness; lack of agency/fiduciary concern; inappropriate judgment; lack of intervention on the patient's behalf; medication errors; lack of prevention; missed or mistaken MD/healthcare provider's orders; and documentation errors. Causes for the error, at the system and practice responsibility levels, were identified in each case.The categories, an assessment of causes of errors, and an examination of the remediation actions taken were the first steps in devising a taxonomy of nursing error, designed with prevention in mind. The authors discuss their work and present the taxonomy.
ISSN:0002-0443
1539-0721
DOI:10.1097/00005110-200210000-00006