Individual, practice, and system causes of errors in nursing: a taxonomy.

Area of Science:

• Nursing Practice
• Patient Safety
• Healthcare Quality Improvement

Background:

• Nursing practice errors can lead to significant harm for patients, families, healthcare providers, and the nursing profession.
• Analyzing serious nursing errors reported to State Boards of Nursing offers potential for developing error-reduction strategies.

Observation:

• A taxonomy of nursing errors was developed by analyzing 21 case studies from 9 State Boards of Nursing files.
• The analysis focused on identifying categories central to the nurse's role in healthcare delivery errors.

Findings:

• Eight categories of nursing errors were identified: lack of attentiveness, lack of agency/fiduciary concern, inappropriate judgment, lack of intervention, medication errors, lack of prevention, missed/mistaken orders, and documentation errors.
• Causes were identified at both system and practice responsibility levels for each case.

Implications:

• This taxonomy provides a framework for understanding and categorizing nursing errors.
• The developed taxonomy is designed with error prevention as a primary goal, aiming to improve patient safety and healthcare quality.