Posted 10 February 2023 - 01:00
Posted 10 February 2023 - 01:00
Features
My biggest mistake as a nurse: how to bounce back from errors
Nurses’ challenging work environments lead to errors – find out how to see these as a springboard to care improvement and not as a career-ending catastrophe
Nurses’ challenging work environments lead to errors – find out how to see these as a springboard to care improvement and not as a career-ending catastrophe
- Mistakes in nursing care are so often traceable to factors such as clunky processes, short-staffing or dysfunction in teams
- How to understand why errors happen so you can address their causes (or take them up with your manager) and stop them from being repeated
- Find out how to play your part in building a learning culture where colleagues’ candour is not punished, but used as a catalyst for change
Mistakes are a normal part of life and nurses are human. That means that nurses, like everyone else, will have to cope with the consequences of making a mistake at some point in their career.
There are different levels of mistakes though – a nurse who misreads a rota and turns up to work an hour early, for example, is not likely to be harming others. But more serious errors in a healthcare settings, such as giving the wrong medication or not using equipment properly, can literally be a matter of life and death.
For nurses, serious errors – depending on context – can lead to disciplinary action, or even the loss of registration.
Why context of the mistake is essential to understand
According to the Nursing and Midwifery Council (NMC), the top three categories of allegations investigated by its fitness to practise panels and found proven in 2021-22 were patient care (26%), including, for example, inappropriate or delayed response to deterioration, followed by prescribing and medicines management (15%) and record keeping (14%).
The NMC does, however, take into account the context in which a mistake happened, and that includes factors such as staffing levels and the culture and environment in which the mistake happened.
‘Sometimes things go wrong, and when this happens it’s vital that professionals feel able to speak up without fear of blame,’ says NMC director of professional regulation Lesley Maslen.
‘There needs to be a positive culture of openness and honesty where people can confidently admit and learn from their mistakes.’
‘These days there is a more open culture, but that isn’t the case across the board, and nurses and others fear retribution from errors’
Carmel Bagness, RCN professional lead for midwifery and women’s health
Ultimately, she says, the NMC’s role is preventing future risk to people who use services, not punishing professionals for past mistakes.
‘When concerns are raised with us, we take the context of the concern into account, we look beyond the individual’s actions and understand the role of other people, the culture and environment they were working in.
‘Then we consider the nurse, midwife or nursing associate’s insight, and any steps they’ve already taken or can take to strengthen their practice. Only then can we understand why something happened and prevent it from happening again.’
Blame culture in nursing: staff need to know candour won’t put them at risk
Nurses have a professional duty of candour to be open and honest when things go wrong. This is important not only so that the mistake can be put right, if possible, but also so it can be examined to see if there are ways to prevent it happening again.
According to RCN professional lead for midwifery and women’s health Carmel Bagness, creating a culture where people feel they can be open when things go wrong is crucial. While she feels this has improved over recent years, more needs to be done.
‘I do feel that these days there is a more open culture, but that isn’t the case across the board, and nurses and others will fear retribution from errors,’ she says. ‘Is there an opportunity for a nurse to put their hand up and say “I’ve made a mistake” or is there a fear factor attached to it?’
There are ways of creating an open culture that isn’t focused on blame, she says. She cites the example of an organisation where she worked, where there was a monthly meeting to discuss mistakes.
‘All the errors that did occur – and there weren’t many – were brought to the meeting confidentially, and we talked about it openly, saying “this has happened – how do we fix it?”.
‘That’s probably one of the best ways because we can say: “Well actually it happened because two people were off sick, so we need to put something in place for the next time.” It’s very much about having that process in place that enables people to feel safe to express their concerns – but I’d say that’s very variable across the piece.’
‘When I was learning to be a nurse, we were made to feel very fearful of making a mistake. That meant people may not have disclosed an error because of fear being disciplined or even sacked’
Jane Douglas, transforming workforce lead – nursing, Scottish Care
Nurses who make mistakes feel devastated, she says. ‘It doesn’t have to be a serious mistake. But that doesn’t matter because you care about the people you’re caring for – that’s the whole reason you’re there. Even something minor will upset a nurse because nobody wants to make that mistake.’
Nurses who make mistakes need support from their managers, she says.
‘If there’s a more serious critical incident it can cause somebody to leave the profession because they feel so bad about it.’
It takes time and energy to support a nurse in that situation, says Ms Bagness – and sometimes these can be in short supply. Occupational health departments can help, but so can peer support, or the manager sitting with the person and taking the time to talk about it.
‘Maybe you can’t fix the mistake but you can fix the person so that they feel better about it. It might be about making sure they get the right further education or they might need time out of that clinical area just to regain confidence.’
Ultimately mistakes tend to come down to human error, she says – and should be treated with empathy and understanding. ‘No nurse goes to work intending to cause harm or to make an error. But we’re all human, and we all have pressures going on.’
Nurses who make mistakes deserve understanding
Mistakes can happen in any setting, says Scottish Care transforming workforce lead – nursing, Jane Douglas.
Creating a culture that encourages openness about errors is crucial – and that includes leaders and senior staff being prepared to admit their own fallibility.
‘Everyone makes mistakes – and anybody who says they’ve never made a mistake probably isn’t actually telling the truth,’ says Dr Douglas, who has previously worked as a care home manager and chief executive, and as chief nurse for the Care Inspectorate in Scotland.
‘When I was learning to be a nurse, we were made to feel very fearful of making a mistake – that was very much the culture. If someone made a medication error, for example, they would take a very hard line, and that meant people may not have disclosed an error because of fear being disciplined or even sacked.
‘But the nursing profession realised this was happening and tried to have much more transparency around encouraging people to open up if they made a mistake.’
5 ways to avoid mistakes – and learn from them when they happen
Jane Douglas, transforming workforce lead – nursing, at Scottish Care advises:
- Have very clear processes for documentation and medications administration, and make sure staff are trained, and understand them
- Encourage all staff to be prepared to challenge each other, even senior colleagues, if they see something being done wrongly
- If you’re asked to do something you know isn’t right, don’t do it – and raise it with your line manager
- Mistakes are a learning opportunity so make sure you have a system for recording errors, analysing them, and sharing the findings. If there is a pattern of errors, there might be common contributing factors, such as staffing at particular times, or skill mix
- As a manager or team leader, create a psychologically safe environment for staff, so they feel comfortable they will be supported when they are open about making a mistake
Managers’ nurse education and training responsibilities
In care homes, as in other settings, there is the potential to make mistakes with equipment and medication, or incorrect risk assessments about a person’s likelihood of falling, for example.
People can also make mistakes because they do not understand legislation, such as laws about capacity – or because they have misinterpreted what they’ve been told by a colleague, she says. In that instance it is up to managers to ensure staff have up-to-date training, and there is a culture that allows people to ask if they are not sure.
Some of these issues can be picked up via annual staff appraisal, or through dedicated sessions such as debriefs or clinical supervision.
‘We should be shifting from individual to organisational responsibility. We need to stop apportioning blame and think about how we can do things better’
Sharon Aldridge-Bent, nurse and leadership consultant
Making a mistake stays with you all your career, says Dr Douglas. ‘I remember making a medication error when I’d only been qualified a year. I had misread the medication dose that I was checking with another nurse. Normally I would do another check at the bedside but on this occasion I didn’t. When I went to check the dose, it was incorrect and he’d already swallowed it.’
Dr Douglas remembers how that felt. ‘My legs went to jelly and I went and told the doctor what had happened. He said it was fine because it was what he was normally having, just a slightly different dose. I was open and honest about it, but honestly, I never, as far as I know, made a medication error again.’
Medication errors are usually avoidable, she says, but when the do occur it’s important to look at the circumstances in which they happen and to take action to prevent them happening in the future.
‘It’s usually a breach in the process in some way – you’ve been disturbed, or two medications look alike, or the medication has been stopped and it’s not clear on the MAR (medication administration record) sheet, or something like that, so you can usually work back to how it’s happened.’
If someone is being interrupted giving medications because they are having to answer the phone, the solution might be, for example, ensuring someone else is carrying the phone while the medications round is taking place.
Does your organisation learn from errors so it can improve care?
Nurses want to be able to learn from mistakes to help improve patient care, according to a survey by Radar Healthcare.
In a report published in October, the company, which supplies incident, risk and compliance software to NHS organisations, analysed incident reporting in secondary care and its impact on patient safety.
It included the views of 100 nursing staff working in UK hospitals. This showed that while 92% of staff said they logged or reported incidents immediately, staff felt 40% of their reports did not lead to better patient outcomes.
Most said they needed more time, extra training, and access to the right technology to be able to report incidents. They also said they wanted detailed feedback on their incident reports and to ensure reports would drive change by sharing what had been learned with front-line staff.
Nurses said that sharing what has been learned from incidents to inform improvements was the most important organisational or cultural change that could be made to improve patient safety outcomes.
Clinical errors naturally make nurses fearful for their registration
Dr Douglas, a part-time lecturer at Queen Margaret University, Edinburgh, is open about her own mistake, and also shared the details when training her care home staff in medications administration. Although it happened almost four decades ago, she recalls the details with great clarity.
‘It did have a psychological impact on me. I knew the patient was going to be all right, but I also knew I had made a mistake, and when you know that you’ve made a mistake, you feel vulnerable. You know that your registration – which is the most important thing to you – is at stake. You worry that there will be a mark next to your name. It really can affect you, and I think some nurses will leave because of it, because they’ve been made to feel that they are not a good nurse.’
Nurse and leadership consultant Sharon Aldridge-Bent says that blame cultures still exist in health services – and that a change of approach is needed to put more focus on prevention.
‘We’ve got loads of patients who have fallen into the stream and we’re good at pulling them out. What we’re not good at is working out why they fell in in the first place. That also applies to mistakes, and I think we need to strip it back and work out why they happened in the first place.’
There aren’t enough nurses and there aren’t enough role models in nursing, she says. This means there aren’t enough people to meet demand – and mistakes happen.
‘We should be shifting from individual responsibility to organisational responsibility, so when mistakes happen it’s to do with the system, not necessarily one person. We need to stop apportioning blame and think about how we can do things better.’
Further information
- Radar Healthcare (2022) Incident Reporting in Secondary Care
- NMC (2022) Annual Fitness to Practise Report 2021-2022