Damage control

Damage control
Nurses respond to newspaper series that examined on-the-job errors, assessing the harm and the benefits of bringing the problem to light

By Anne Federwisch, OTR
November 13, 2000
Photo: Digital Stock

Many nurses thought the Chicago Tribune's three-part series on nursing errors did more harm than good.


	You've read the article. Now tell us what you think. Related sites Quality Interagency Coordination Task Force Chicago Tribune series on nursing errors "To Err is Human: Building a Safer Health System" American Nurses Association American Association of Colleges of Nursing No easy answers Everyone makes mistakes, including nurses. "But we can eliminate a lot of mistakes from the systems approach," said Mary Foley, MS, RN, president of the American Nurses Association. That involves creating fail-safe policies and procedures that allow errors to be caught before they reach patients, and analyzing mistakes if they do happen to pinpoint where the system broke down. That’s easier said than done, though. The blame game Nonpunitive error reporting is key to making a systems approach work, said Mary Wakefield, Ph.D., RN, FAAN, director of the Center for Health Policy, Research and Ethics at George Mason University in Fairfax, Va. She was the only nurse on the Institute of Medicine panel that authored the 1999 report "To Err is Human." One of the report’s recommendations was mandatory reporting of serious mistakes leading to death or injury. "As long as we have a culture of blame, people are not going to come forward and say, ‘Oops, this is what I just did,’" she said. "That’s the last thing we want to happen. You can’t analyze errors and try to prevent them from happening if you’re driving them underground." So far, nonpunitive reporting isn’t universal. "I believe nurses are cautious because it’s not a blame-free environment," said Pat Cason Merenda, RN, a staff nurse at Detroit Medical Center. "When something goes wrong, they [administration] don’t look at changing the context; otherwise, they would look at staffing. And they don’t." National summit The publicity that the IOM report garnered prompted several organizations including health care facilities, professional organizations and the federal government to study ways to reduce errors. But the list of things to investigate is huge. A steering committee for the National Summit on Medical Errors and Patient Safety Research set a national agenda for study, based on testimony by consumers, health professionals and researchers at the September meeting. (Patricia Underwood, Ph.D., RN, first vice president of the American Nurses Association, was one of the presenters.) Agenda topics include epidemiology of errors, infrastructure to improve patient safety, information systems and determining which interventions should be adopted. Each topic includes more than a dozen subtopics. Steps to safety Safety experts often list improving technology and standardizing procedures as other important steps to reducing errors. Yet even those strategies have drawbacks. "Some people are putting too much reliance on technology," Foley said. If you don’t have properly trained staff to administer that technology, errors still can result. The best protocols may be error-free on paper, but without supervision and monitoring, shortcuts can undermine their efficacy. "Even the best systems need to be constantly monitored," Foley said. ~ Anne Federwisch, OTR

When the Chicago Tribune published its three-part series on nursing errors in September, Associated Press and Internet versions spread its effect well beyond the confines of the Windy City. In the workplace, in cyberspace and in letters to the editor, nurses from across the country voiced their opinions, ranging from acrimony to accolades.

The Tribune analyzed 3 million federal and state records to quantify nurses’ role in medical errors. According to their study, nursing action – or inaction – accounted for 1,720 deaths and 9,584 injuries since 1995. Investigative reporter Michael Berens, who penned the articles, said the paper received more than 1,000 letters in response to the trilogy. Twenty-five percent were "overwhelmingly negative," he said.

Controversial headlines
Many clinicians thought the headlines, particularly the initial one blaring "Nursing mistakes kill, injure thousands," could just as well have read "Disease doesn’t kill patients, nurses do." Yet many also gave the stories credit for bringing to the public’s attention that "Cost-cutting exacts toll on patients, hospital staffs," as the first segment’s subhead aptly explained.

But the merits of the text didn’t outweigh the killer headline, according to Candy Weiland, RN, a staff nurse at Sutter Coast Hospital in Crescent City, Calif. "The headline was sensationalized," she said. "It would have been better to say ‘Short staffing by hospitals kills patients.’ Let’s put the problem back where it belongs."

Ann Cather, RN, a certified emergency and critical care nurse and legal nurse consultant, thinks the pieces attacked nurses unfairly. "My initial reaction to the first article was: They’re laying the blame at the feet of the nurse. That everything that goes wrong, goes wrong because the nurse makes a mistake," said the staff nurse for MedStaff in Martinsburg, W.Va.

Mary Foley, MS, RN, president of the American Nurses Association, also faulted the headlines as misleading. "Bad headlines, great articles," she said. "The problem is, frightening people into ‘Nursing mistakes kill and injure thousands,’ I think undermines the confidence the public has – and is well-placed – in the profession of nursing."

Berens defended the headlines in an interview with NurseWeek. "Given the total of the story, the headlines do accurately portray some of the message that we were trying to say. I don’t think any headline can sum up hundreds of inches of a story. I think it’s incumbent on the reader to go past the headline."

Lynn Snider, RN, a certified emergency nurse, went past the headline, but she’s not convinced that the public did. "In a way, the first article did talk about why nurses are so overworked. That there are fewer nurses and more unlicensed assistive personnel," said Snider, a staff nurse at Methodist Medical Center in Dallas. "But I don’t know that people read that far. It was a very long article."

Even if readers did get through the 5,300-word body of the first article, "what they’re going to remember is so many deaths that were caused by nurses," Weiland said.

More balance
Some nurses said Berens should have balanced his series by including examples of how nurses’ quick interventions save lives. "It happens all the time," said Carolyn Williams, Ph.D., RN, FAAN, president of the American Association of Colleges of Nursing. "But because nothing bad happened, it’s not news."

But only so much can go into any one story, Berens said. "It would have been nice to have days and days of stories saying that nurses have saved lots of lives. We kind of felt that was understood. We were trying to show the other side of this nursing equation."

He should have balanced that equation by focusing on nursing errors within the context of the entire health care team, some nurses argued. The study did not try to quantify any other discipline’s contribution to medical errors.

"We chose to look at this through the prism of nursing," Berens said. His theory was that nurses are the backbone of the health care system, yet no one had analyzed their effect on lethal mistakes. "We looked for specific linkage to nursing. We didn’t just track hospital deaths. We tracked deaths linked specifically to some aspect of nursing care."

He does not know what percentage of overall deaths nursing errors account for. "We have no idea. No one does," Berens said.

Nursing leaders don’t want to quibble about numbers.

"One unnecessary death is one too many," Foley said. But by focusing solely on nursing, the public may have gotten the wrong message, according to Mary Wakefield, Ph.D., RN, FAAN, director of the Center for Health Policy, Research and Ethics at George Mason University in Fairfax, Va.

Wakefield was the only nurse on the Institute of Medicine committee that produced "To Err is Human: Building a Safer Health System."

The comprehensive report made headlines of its own in 1999 when it suggested that medical mistakes claim 44,000 to 98,000 lives annually in the United States – more than AIDS, car accidents or breast cancer.

Berens and others dispute the accuracy of those numbers because the authors extrapolated the data based on studies in only a few states.

By not analyzing other disciplines, the Tribune articles "left blame at the doorstep of the nursing profession, but patient errors are a phenomenon that everyone owns," Wakefield said. "It isn’t just the individual nurse; it isn’t just the nursing profession."

Narrowly focusing on one particular provider misses the point and the major source of errors, she said. "In the vast majority of cases, the IOM report says, it isn’t an individual performer that results in an error," Wakefield explained, "but a confluence of factors and general organizational characteristics that allow an error to be committed."

Championing nursing
Berens didn’t intend the series to be a hit piece on nursing. "My goal – and the Tribune’s – was to champion the role of nursing through a detailed, unflinching examination of patient care within America’s hospitals," said Berens, whose mother is a retired RN. "I think the cold numbers detailing death and injury were clearly offset by a key statement in the first day’s story noting that nurses are often victims of a health care system too often measured by dollars."

One of the positive aspects about the articles is that it underscores the crucial role nurses play in health care, Williams said. "Nurses make important decisions. That comes through" in the pieces, she said. "Nursing does matter."

Unfortunately, people don’t seem to realize that until something goes wrong. "I think some people’s reaction to this [series] is that the only time we get any press is when things go bad," she said.

Yet sometimes the bad needs to be reported, Foley said.

She applauded Berens for bringing to the public’s attention what the ANA has been sounding the alarm about since at least 1994: that understaffing or replacing RNs with lesser-trained clinicians can have dire consequences. "These articles and the IOM report are the prodding that needed to happen in this country to make all of the disciplines work together" to reduce errors, she said.

Although the stories may "wake some people up to the crisis in health care," Snider doesn’t think the overall consequence on nursing was positive.

"With the nursing shortage as bad as it is," she said, "who’s going to want to be a nurse if they see something like that written in a national newspaper?"