Promoting patient safety by monitoring errors: A view from the middle

Abstract

Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a culture that fosters reporting of errors. Their staff nurses expect the managers to support them after errors occur. Drawing on interviews with 20 nurse managers from three tertiary care hospitals, the study identifies key exemplars that illustrate how managers monitor nursing errors. The exemplars examine how nurse managers: (1) sent mixed messages to staff nurses about incident reporting, (2) kept two sets of books for recording errors, and (3) developed routines for classifying potentially harmful errors into non-reportable categories. These exemplars highlight two tensions: the application of bureaucratic rule-based standards to professional tasks, and maintaining accountability for errors while also learning from them. We discuss how these fundamental tensions influence organizational learning and suggest theoretical and practical research questions and a conceptual framework.

Citation

Tamuz, M., Russell, C.K. and Thomas, E.J. (2008), "Promoting patient safety by monitoring errors: A view from the middle", Savage, G.T. and Ford, E.W. (Ed.) Patient Safety and Health Care Management (Advances in Health Care Management, Vol. 7), Emerald Group Publishing Limited, Leeds, pp. 69-99. https://doi.org/10.1016/S1474-8231(08)07004-3