||Studying ER Medical Error to the Design of Training Interventions for Novice Nurses
||Department of Industrial Design
Emergency (ER) departments are a particularly error-prone treatment setting, in which ER novice nurses are a group at high risk of generating medical errors. This study investigated the occurrence of ER medical errors to design innovative training interventions for novice nurses. First, by using a system approach, we examined active and latent errors to investigate the causes of common ER medical errors, and then analyzed deficiencies in current training programs. The results were used to design innovative training interventions for mitigating medical errors that occur in ER settings. Semistructured interviews with 34 ER nurses (15 preceptors and 19 novice nurses) were conducted to determine extant medical errors occurring in ER departments. Subsequently, content analysis was performed on the collected interview texts and data. The research results were then analyzed according to the characteristics of medical errors and four categories of medical errors were identified: (1)medication error, (2)error in sample submission for testing, (3)delay in treating and forgetting to treat deteriorating patients, (4)error in equipment and tube setting. Among these types of errors, medication error occurred the most frequently. In terms of active errors, medication error most frequently occurred in the form of skill-based error of omission, followed by skill-based error of commission. It means novice nurse often forget to obey “five rights” before executing order. The occurrence of these errors attributes to latent error, including excessive psychological precursors, and rash working atmosphere. In terms of error in sample submission for testing involved skill-based error of omission, and rule-based error of omission. The former error means novice nurse often forget to paste sticker of specimen, leading to the failure of identifying specimen identity. The latter error refers to novice nurse fail to proceed right process to take specimen. And these error attributes to not only psychological precursors but also poor team work where novice nurse often carry out other nurses’ oral request without checking if the request is right or not. Concerning delaying in treating and forgetting to treat deteriorating patients, it’s associated with rule-based error of omission. It means novice nurse often miss the symptom of patients, giving rise to the omission of carrying out treatment in time. Apart from psychological precursors, training failure is also responsible for the occurrence of error. Inadequate training leads novice nurse unable to utilize knowledge in hand and do proper time management in clinical settings. Finally, error in equipment and tube setting was mostly associated with rule-based error of omission, followed by skill-based error of omission. The former error represents novice nurse often neglect the necessity of execute constraint or sedation on patients leading to patient extubated himself. The letter one means novice nurse forget to recheck the tube during the shift, leading to slippage off where it supposed to be. And these error attributes to excessive psychological precursors and poor team work where nursing staff fail to clarify responsibility of caring patients with intubation. In terms of the status of quo of training program. Novice nurses thought that existing course lack of the utilization of knowledge and actual operation. Further, most of training content depends on what clinical situation they encountered without systematic organization of teaching.
This study contributed to relevant research fields by providing an analysis of ER medical errors from a systematic perspective. The findings can serve not only as inspirations for future research on ER medical errors, but also as a reference for designing concrete and effective training interventions. This study provides the following recommendations. Medication errors can be minimized by assigning nurses multiple practical exercises to improve their proficiency and precision in administering drugs to patients. Novice nurses should be familiar with nursing procedures so that they could efficiently carry out the procedures even under time constraints. Furthermore, novice nurses could be provided with clinical handbooks that allow them to revise drug-related knowledge at any time. They should participate in case study discussions where they can really apply their knowledge rather than engage in rote learning. To address error in sample submission for testing, handbooks detailing relevant processes could be provided to novice nurses so that they could search for and learn complex procedures at any time. In addition, relevant instruments, test tubes, and specimen samples should be clearly labeled to serve as a reminder to novice nurses about paying attention to detail. To mitigate error in equipment and tube setting, novice nurses could learn how to operate instruments by showing them the actual operations of an entire process and assigning them practice tasks. Regarding delay in treating and forgetting to treat deteriorating patients, training units should compile a guideline to determining and treating patient symptoms and train novices to develop heightened sensitivity toward changes in disease conditions, even when in a stressful environment. Finally, novices must also be trained in sorting the priority of multiple tasks to prevent focusing on miscellaneous issues and consequently omit executing procedures that are really needed.
TABLE OF CONTENTS viii
LIST OF TABLES xi
LIST OF FIGURES xii
Chapter 1 Introduction 1
1.1 Research Background and Motivation 1
1.2 Research Objectives 4
1.3 Research Scope 5
Chapter 2 Literature Review 6
2.1 Systematic Risk Analysis and Management 6
2.2 Active Errors 6
2.2.1 Active Errors: Human Errors 7
2.2.2 Active Errors: Types of Errors 9
2.3 Latent Errors 9
2.3.1 Latent Errors: Design Failure 10
2.3.2 Latent Errors: Organization and Environment Failure 10
2.4 Summary 11
Chapter 3 Research Method 13
3.1 Participants 13
3.2 Instrument 15
3.3 Semistructured Interview 15
3.4 Data Analysis 17
Chapter 4 Results 21
4.1 Medication Error 21
4.1.1 Condition of Error 21
4.1.2 Causation of Active Error 22
4.1.2 Causation of Latent Error 24
4.1.3 Systematic Overview of Error Causation 27
4.2 Error in Sample Submission for Testing 29
4.2.1 Condition of Error 29
4.2.2 Causation of Active Error 29
4.2.3 Causation of Latent Error 31
4.2.4 Systematic Overview of Error Causation 33
4.3 Delay in Treating and Forgetting to Treat Deteriorating Patients 34
4.3.1 Condition of Error 34
4.3.2 Causation of Active Error 34
4.3.3 Causation of Latent Error 35
4.3.4 Systematic Overview of Error Causation 37
4.4 Error in Equipment and Tube Setting 38
4.4.1 Condition of Error 38
4.4.2 Causation of Active Error 38
4.4.3 Causation of Latent Error 40
4.4.4 Systematic Overview of Error Causation 41
4.5 Current Situation of Emergency Medicine Training 42
4.5.1 Problems in Formal Training Programs 43
4.5.2 Problems in Informal Training Programs 44
4.5.3 Training Suggestions as Proposed by Interviewees 47
4.5.4 Summary 49
Chapter 5 Discussion 51
5.1 Causation of Medication Error 51
5.2 Causation of Error in Sample Submission for Testing 54
5.3 Causation of Delaying Treatment/Forgetting to Treat Deteriorating Patient 55
5.4 Causation of Error in Equipment and Tube Setting 57
5.5 Error in Current Emergency Medicine Training Models 59
5.5.1 Formal Training 59
5.5.2 Informal Training 60
Chapter 6 Design Recommendations 64
6.1 Preventing Medication Error 64
6.2 Preventing Error in Sample Submission for Testing 66
6.3 Preventing Delay in and Forgetting Treatments 67
6.4 Prevention of Error in Equipment and Tube Setting 69
Chapter 7 Conclusion 71
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