Exploring omissions in nursing care using retrospective chart review: An observational study

Area of Science:

• Nursing Science
• Patient Safety Research
• Healthcare Quality Improvement

Background:

• Omissions in nursing care pose a significant risk to patient safety.
• Previous research primarily relied on nurse surveys, limiting scope and patient-level analysis.
• Retrospective chart review offers a novel methodology for assessing omitted nursing care.

Purpose of the Study:

• To characterize and quantify omitted nursing care using retrospective chart review.
• To evaluate the frequency and types of nursing care activities omitted during inpatient stays.
• To establish a patient-level analysis of nursing care omissions.

Main Methods:

• An observational, single-center study was conducted in two German neurological inpatient units.
• A random sample of 100 patient admissions was analyzed.
• A structured chart review protocol was developed and applied to assess the full range of nursing activities for omissions.

Main Results:

• A total of 1885 nursing activities were reviewed, averaging 19 per patient.
• Over half (52%) of all assessed nursing activities were fully or partially omitted.
• Emotional care was the most frequently omitted activity (88%), while vital sign monitoring occurred only 50% of the targeted times.

Conclusions:

• Retrospective chart review effectively assesses a broad spectrum of nursing activities for omissions.
• This methodology provides novel patient-level data on omitted nursing care.
• The developed chart review protocol complements existing survey methods, offering new insights into nursing care omissions.