By Challenges in the Critical Care Workplace

By Elizabeth A. Henneman, RN, PhD, CCNS, Anna Gawlinski, RN, DNSc, Fidela S.Blank, RN, MBA, Philip L. Henneman, MD, Deovina Jordan, PhD, MD, MSN, MPH,RN-BC, and Janice B. McKenzie, RN

Background Medical errors are common in intensive careunits. Nurses are uniquely positioned to identify, interrupt,and correct medical errors and to minimize preventable adverseoutcomes. Nurses are increasingly recognized as playing arole in reducing medical errors, but only recently have theirerror-recovery strategies been described.Objectives To describe error-recovery strategies used by criticalcare nurses.Methods Data were collected by audio taping focus groupswith 20 nurses from 5 critical care units at 2 urban universitymedical centers and 2 community hospitals on the East andWest coasts of the United States.Transcript content was ana-lyzed as recommended by Krueger and Casey.Results Analysis of focus group data revealed that nurses incritical care settings use 17 strategies to identify, interrupt, andcorrect errors. Nurses used 8 strategies to identify errors:knowing the patient, knowing the “players,” knowing the planof care, surveillance, knowing policy/procedure, double-checking,using systematic processes, and questioning. Nurses used 3strategies to interrupt errors: offering assistance, clarifying,and verbally interrupting. Nurses used 6 strategies to correcterrors: persevering, being physically present, reviewing orconfirming the plan of care, offering options, referencingstandards or experts, and involving another nurse or physician.Conclusions These results reflect the pivotal role that criticalcare nurses play in the recovery of medical errors and ensuringpatient safety. Several error-recovery strategies identified inthis study were also reported by emergency nurses, providingfurther empirical support for nurses’ role in the recovery ofmedical errors as proposed in the Eindhoven model. (AmericanJournal of Critical Care. 2010;19:500-509)

STRATEGIES USED BY

CRITICAL CARE NURSES

TO IDENTIFY, INTERRUPT,AND CORRECT MEDICAL

ERRORS

©2010 American Association of Critical-Care Nursesdoi: 10.4037/ajcc2010167

Challenges in the Critical Care Workplace

This article is supplemented by an AJCC Patient CarePage on page 510.

500 AAJJCCCC��AMERICAN JOURNAL OF CRITICAL CARE, November 2010, Volume 19, No. 6 www.ajcconline.org

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Most adverse events are believed to result fromsystem failures, many of which have been identifiedand preliminarily addressed.11 Although the impor-tance of addressing system problems has beenemphasized, clinicians at the point of care remaingenerally accepted as the final safeguard against adangerous situation adversely affecting patients. Incritical care settings, nurses caring for patients at thebedside are well positioned to transform potentiallyadverse outcomes into “near-miss” situations, thusimproving patient safety.

Nurses play a role in ensuring patient safety byrecognizing and reducing complications.13,14 Althoughnurses’ role in preventing medication errors wasidentified more than a decade ago,7 only recentlyhas nurses’ pivotal role in addressing many othertypes of medical errors been identified.2,3,5,6,8,9

Experts have suggested that patient safetydepends as much on preventing devastating inci-dents by improving systems as it depends on maxi-mizing the ability of individuals at the point of care

to stop dangerous situations by identifying, inter-rupting, and correcting errors.7,9,10,15,16 Nonetheless,little attention has been paid to the integral roleof bedside nurses as the final defense againstsystem failures and dangerous situations.6,9 Toaddress this gap in knowledge, we conducted thisexploratory study to describe strategies used bycritical care nurses to identify, interrupt, andcorrect medical errors.

Theoretical FrameworkOur theoretical framework was the Eindhoven

model for investigating near-miss events.15 Thismodel was adapted by Hennemanand Gawlinski6 to conceptualizethe nurse’s role at the point of carein preventing adverse outcomes forpatients (see Figure).

The Eindhoven model demon-strates the relationship betweenhuman operator, technical, andorganizational failures and thedevelopment of incidents that mayor may not lead to adverse out-comes. The model also proposesthat high-risk situations, whichcan develop from human operator,technical, and organizational fail-ures, may be prevented by adequate system defenses.In health care settings, if a high-risk situation is notaverted by adequate system defenses, it will not beinterrupted and will therefore threaten patient safety.Bedside nurses at the “sharp end of care” are wellpositioned to convert such potentially dangerous sit-uations into near-miss events by identifying, inter-rupting, and correcting errors. Error recovery occurswhen the developing incident is intercepted to pre-vent an adverse outcome for a patient.

Medical errors and adverse events are common in intensive care units,1-5 andnurses are often involved in medical error recovery (ie, identifying, interrupting,and correcting medical errors) and preventing adverse outcomes.6 Althoughnurses have been recognized for their role in reducing the number of med-ical errors,2,4,5,7,8 only recently have nursing strategies for error recovery been

described in the literature.6,9 Analysis of medical errors and adverse patient outcomes by theInstitute of Medicine10,11 and others7,12 has shown that these errors result from both human andsystem failures. These analyses have led the health care community to issue a call to action tobegin systematically addressing medical errors. This action plan requires investigating boththe root causes of errors and methods for reducing the number of adverse events.

About the AuthorsElizabeth A. Henneman is an associate professor in theschool of nursing at the University of Massachusetts inAmherst. Anna Gawlinski is director of evidence-basedpractice at the University of California Medical Center andSchool of Nursing in Los Angeles. Fidela S. Blank is a clini-cal research coordinator in the department of emergencymedicine at Baystate Medical Center in Springfield, Massa-chusetts and an assistant professor at Tufts UniversitySchool of Medicine, Boston, Massachusetts. Philip L.Henneman is a professor of emergency medicine atTuftsUniversity School of Medicine and an attending physicianin the department of emergency medicine at Baystate Med-ical Center. Deovina Jordan is an associate professor inthe school of nursing at California State University, Fuller-ton. Janice B. McKenzie is currently retired from nursing.

Corresponding author: Elizabeth A. Henneman, RN, PhD,CCNS, 357 Green Hill Road, Longmeadow, MA 01106 (e-mail: [email protected]).

Clinicians at thepoint of careremain generallyaccepted as thefinal safeguardagainst a danger-ous situationadversely affectingpatients.

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2 urban university medical centers and 2 commu-nity hospitals in the eastern and western UnitedStates. Inclusion criteria were as follows: (1) has atleast 6 months of critical care experience as a staff orcharge nurse and (2) is English speaking. Subjectswere paid for participating. The sample of 20 nurseswas sufficient to achieve theoretical saturation,16

that is, analysis of transcripts from the focus groupsshowed redundancy in the information providedby study participants related to error recovery.

Before they participated, all nurses were giveninformation about the study and signed a consentform. Participants’ confidentiality and anonymitywere maintained by not recording any unique iden-tifiers on taped interviews or transcribed reports.

ProcedureThe procedure for conducting the focus groups

is described in detail elsewhere9 (Table 1).

Data CollectionData were collected by posing predetermined

questions (Table 2) in 7 audio-taped focus group ses-sions (each 60 to 90 minutes long). These questionswere developed by the researchers on the basis of theirclinical experience, theoretical knowledge of errorrecovery, and results of a study on medical error recov-ery in an emergency department.8,9 Questions werereviewed for content validity by 5 experts: 2 expert crit-ical care nurse clinicians, a physician with expertise inpatient safety, and 2 nurse researchers, one of whomis a patient safety expert and a practicing critical carenurse. Focus groups were moderated by one of theauthors (E.A.H.) and a trained research assistant, bothof whom used recommended methods.16

Data AnalysisAudio tapes were transcribed verbatim by a uni-

versity transcription department. Transcriptionistswere not told about the purpose of the study. Thecontent of transcripts was independently analyzedby 5 reviewers.16 Patterns and trends were identifiedand summarized into themes. Themes were clus-tered into categories of interest, namely strategiesfor identifying, interrupting, and correcting errors.These independent findings were then reviewedwith the research team. Disparities and inconsisten-cies were addressed, and themes were revised toreflect consensus categorizations.

ResultsThe 20 participating nurses had a median of 12

years of experience in critical care (range, 8 monthsto 30 years). They perceived critical care units as

MethodsDesign

In this exploratory study, we used focus groupsto explore strategies used by critical care nurses toidentify, interrupt, and correct errors. The focus groupmethod was appropriate because it increases under-standing of complex processes and explores topicsin depth.

Sample and SettingParticipants (20 registered nurses) were recruited

by convenience sampling from 5 critical care units at

Table 1 Overview of focus group procedures

Approval obtained from institutional review board

Participants recruited via posted flyers

Research assistants trained in focus group method

Focus groups held mornings and evenings

Focus groups led by a moderator (E.A.H.) and a trained research assistant

At start of each focus group, Institute of Medicine definition of medicalerror (ie, “failure of a planned action to be completed as intended orthe use of a wrong plan to achieve an aim”) read to participants alongwith Institute of Medicine data10 on numbers of medical errors

Error recovery strategies elicited by posing short, hypothetical case studiesand asking participants to recall experiences in a similar situation

At conclusion of each focus group, key points summarized and clarificationrequested when needed

After each focus group, moderator and research assistant debriefed andnotes reviewed

After completion of all focus groups, transcripts of audiotapes and fieldnotes sent to focus group participants for comments, clarification ofany statements as needed, and addition of any thoughts not discussedduring the focus group sessions

Figure Modified Eindhoven model of error recovery. Reprinted from Henneman and Gawlinski,6 ©2004 with permission from Elsevier.

Humanoperatorfailure

No

Yes

Yes

No

Dangeroussituation

Nearmiss

Adequate

defense

DevelopingincidentOrganizational

failure

Technicalfailure

Noadversepatient

outcome

Adversepatient

outcome

Nursingrecovery



Another useful strategy described by nurses forimproving safety was knowing other patients in theunit: “We keep our eye on each other’s patients—you know them because you’ve had them before.”

Knowing the Players. In discussions about meth-ods to identify, interrupt, and correct errors, nursesfrequently described the need to craft differentstrategies depending on the specific individualswith whom they were working. Nurses mentionedusing individualized approachesdepending on a team member’s per-sonality or preferences. One nursesaid, “ . . . and know the MD . . .what he is likely to order or notorder.” Similarly, another nurse said,“I see who I am taking over from,and that can really play into howthe next 3 or 4 hours of the shift aregoing to be.”

Knowing the Plan of Care.Another important strategy for iden-tifying errors was knowing the planof care or recognizing the lack of acomprehensive plan. Reviewing theplan of care, for example, at thechange-of-shift report or during rounds helpednurses find errors in the current plan (eg, wrongmedication dose being administered). In addition,nurses described their role in finding errors of omis-sion, when they recognized a lack of a comprehen-sive plan for a patient (eg, failure to prescribe anecessary medication). For example, one nurse said,

having a high potential for medical errors, whichthey attributed to factors including the high acuity ofpatients, inadequate nurse to patient ratios, increasedwork demand, and decreased resources. One nursesaid, “Years ago, in the intensive care unit, you onlyhad one patient. You thought of all aspects of thatpatient. Now there are 2 patients, maybe 3.”

The nurses reported that some of the mostchallenging, error-prone situations were related tonegative interactions with other members of thehealth care team. Common themes in discussingfactors that negatively influenced nurses’ ability tocare safely for patients were intimidation by nurseand physician colleagues and poor communication.For example, one nurse said, “You know who youcan or can’t call without consequences….” Anothersaid, “If you intimidate me, I’m not ever going tocome to you . . . I will avoid asking you at any cost.I will even take the chance of making that error.”

Identifying ErrorsNurses’ descriptions of the strategies used to

identify errors in critical care settings revealed 8themes: knowing the patient, knowing the “players”(other team members), knowing the plan of care, sur-veillance, knowing policy/procedure, double-checking,using systematic processes, and questioning.

Knowing the Patient. A recurring theme relatedto strategies for identifying errors was “knowing thepatient.” Nurses described the importance of know-ing all aspects of the patient, including medical andmedication histories, not only to give the highestquality care but also to recognize errors. Knowingthe patient mandated obtaining an accurate andcomprehensive report from the transferring unit orat change of shift. This strategy also involved estab-lishing relationships with the patient and thepatient’s family. In particular, nurses described theirfamiliarity with the patient’s therapy and responseto that therapy over time as important for identify-ing problems and errors. As one nurse said, “Conti-nuity is very important.” Another said, “You get toknow the patient. How? You listen to what otherpeople say. But you also look at and listen to thepatient. And see what’s going on.” A third nursecommented, “Read the history and physical . . . youcan learn a lot about what the plan is, what is goingon with the patient.”

Nurses also described the important role of thepatient’s family members in helping nurses to knowthe patient: “Having the family at the bedside isvery important because they’ll notice it [a problem]before you would; they know exactly what they[patients] are normally like.”

Table 2 Sample questions used in the focus groups

I want you to imagine yourselfworking in the critical care unit.It’s a good shift. You feel goodabout your work and aren’t veryconcerned that errors are beingmade (by yourself or others).

I want you to imagine it’s a busyday in the critical care unit.You sense a high probability oferrors being made.

Now I want you to think about asituation in which somethingwas ordered for a patient thatyou thought was inappropriate(eg, wrong medication, proce-dure).

•Describe the critical care unit to me. •Who is there/not there?•What is happening/not happening?

•What is happening that makes youfeel that way?

•What kinds of things would you bedoing in this setting to identify anerror?

•Describe what you do when youcome across an inappropriate order?

•When you are concerned that adecision or plan is wrong, do yousuggest a different plan?

•What makes it easier to suggest anew plan?

•What makes it harder to suggest anew plan?

Hypothetical situation Questions

Common factorsthat negativelyinfluenced nurses’ability to caresafely for patientswere intimidationby nurse and physician col-leagues and poorcommunication.



report forms, 24-hour chart checks, medication rec-onciliation, and bedside “checks” at change of shift.One nurse commented, “I’ll know from roundswhat the plan is, and I’ll know what the attendingmeant . . . .” Another said, “I have my headings [ona report sheet] and I have to put something under-neath all my headings. If you don’t mention some-thing, I’ll say, ‘you skipped that part.’”

Questioning. A useful strategy for identifyingerrors in general, but particularly with novice clini-cians, was questioning. Participating nurses describedquestioning novice nurses or physicians duringchange-of-shift report or multidisciplinary roundsto prompt them to discuss their decision or actionsin more detail. Like other strategies, questioningafforded nurses an opportunity to review a plan ofcare without offending another team member. Asone nurse said, “I’ll do a more thorough report andask questions that would make them think aboutwhat is going on with their patient.” Another nursegave an example of using this strategy with a physi-cian: “Would you review your orders with me, par-ticularly for this very sick patient?”

Interrupting ErrorsNurse participants discussed their role in inter-

rupting errors that they and their colleagues had com-mitted. The ability of nurses to interrupt an error wasinfluenced by their experience and confidence and bythe ability and experience of the other individualsinvolved/available. Much like strategies to identifyerrors, strategies to interrupt errors were frequently tai-lored to particular nurses or physicians. Nurses alsodescribed the importance of having their nurse col-leagues’ support when an error involved a member ofthe health care team who was perceived as nonrespon-sive or intimidating. One nurse explained, “You haveto be pragmatic and use different approaches with dif-ferent MD personalities.” Another commented, “Takeopinion poll—should I call?” A third said, “I reallythink a lot about what I say before I call.”

Regardless of who was involved, highly experi-enced and confident nurses reported feeling generallycomfortable with interrupting an error. These samenurses often reflected, with regret, about a time whentheir inexperience or lack of confidence prohibitedthem from interrupting an error they believed mayhave adversely affected a patient. A prior negativeexperience with an individual clinician appeared tobe a critical factor that diminished the nurse’s desireto interrupt an error involving the same clinician.

Several nurses described experiences in whichthey were unable to interrupt an error despite theirapparently (to the researchers) extraordinary attempts.

“I’ve caught things because I knew what the patientwas on a few days ago.” Another nurse said, “Ialways . . . when I get the orders . . . check andthink. Why do they want to do this? What’s goingon? What’s the rationale for this?”

Surveillance. Nurses in this study described col-lecting data in a systematic and ongoing manner,which included assessing both the patient and the

patient’s environment. The nursesoften referred to systematicallyassessing patients by scanning thepatient and the patient’s immediateenvironment. For example, a disor-ganized environment would alertnurses to the potential for either avery sick patient who needed somuch attention that the nurse goingoff duty was unable to “keep up” orto a disorganized nurse who mayhave missed important patientneeds. One nurse said, “I walkaround the room, clean it up, and

as I am cleaning it, I see things, like is it organized? . . . seeing faces, listening all the time to the soundof the room . . . .” Another nurse said, “Go in andsee the patient first thing—make sure you have yourright drips hanging. . . .” Similarly, a nurse com-mented, “It’s pretty systematic . . . Observation skillsreally, just paying attention to what’s around me.”

Knowing Policies/Procedures. Another strategydescribed as important in identifying and interrupt-ing medical errors was awareness of the unit’s poli-cies and procedures. Some of the most commonerrors in the units were related to new nurses orphysicians not being aware of policies or procedures(eg, how medications should be administered). As

one nurse explained, “I’ll say, wecan’t give it [a medication] becausewe don’t have a central line.”

Double-checking. A frequentlymentioned strategy for identifyingerrors was double-checking physi-cians’ orders or interventions withother nurses. Nurses commonlyused the example of checking med-ication infusion rates or “computa-tion constants” for medicationinfusion rates. One nurse said,

“They want me to do this. What do you think?”Another said, “Does that make sense to you?”

Using Systematic Processes. A common theme orstrategy for identifying errors was using policy- andunit-based system processes. For example, errors wereidentified by multidisciplinary rounds, structured

Nurses describedtheir familiarity

with the patient’stherapy and

response to thattherapy over timeas important for

detecting problemsand errors.

Nurses describedtheir role in findingerrors of omissionwhen they recog-nized the lack of a

comprehensive planfor a patient.



These nurses vividly recalled the circumstances ofthese events, many of which had occurred yearsearlier. The nurses’ comments suggested that situa-tions where they could not interrupt a serious errorwere rare. The majority of these situations involvedpain management, end-of-life decision making, ordisagreements between physicians about a plan ofcare, with nurses ”caught in the middle” or havingtheir opinion/arguments ignored.

Among the methods used to interrupt errors, 3themes emerged: (1) offering assistance, (2) clarify-ing, and (3) verbally interrupting.

Offering Assistance. Several very experienced nursesdescribed the offering of assistance, in a nonthreat-ening and supportive manner, as a means to inter-rupt an error. This strategy, although appearing passive,was described as both effective and manageableeven for less assertive or novice nurses. The nursesalso stressed the usefulness of this approach in sav-ing face for novice clinicians and in avoiding anxi-ety and mistrust by patients and family members.The importance of approaching other clinicians ina helping manner rather than in a confrontationalmanner (especially in front of patients and families)appeared to be both consistent with their role asnurses and paramount to their role in interruptingerror. One nurse stated:

I’m not one of those who can say “you must doit” [wear a cap and mask when inserting a cen-tral line]. I’m a little on the passive side. I takeit [the cap and mask] in and hand it to them. Everything goes a long way.

Another nurse gave a similar example:

I’ll say “did you get some pain medicine,” know-ing that they hadn’t because they don’t knowhow to get into the PIXIS [medication dispens-ing system]. But that is making them stop andthink about what they needed. And then I offer,“Why don’t I go get you some?”

Clarifying. Nurses also interrupted errors whenthey were unsure of an order, the plan of care, orthe appropriateness of a plan of care by using thestrategy of clarifying. Clarification was frequentlyframed in the form of a question, with the goal ofbeing tactful when interrupting an error. One nurseexplained, “I don’t so much say ‘no,’ as ask why.For example, why did you order this for this patient?”A similar example was given by another nurse:“Why did you order this for so and so [regarding anorder being given for the wrong patient]?”

Verbally Interrupting. When the potential for anadverse event was high, particularly if an errorinvolved pain or sedation management, nurses

halted an activity by using a direct, verbal warning.Nurses mentioned the need to verbally interrupt ina manner that would not create unnecessary anxietyfor patients or family members, for example, by ver-bally interrupting outside the patient’s room. Theyalso stressed the importance of explaining, when-ever circumstances permitted, to theirphysician or nursing colleague theirreason for not carrying out an order.Examples given were “I said, holdon. Just don’t do anything. Justhold on,” and “I said no. Stop now.”

Correcting ErrorsParticipants reported that most

errors were identified and inter-rupted early. When these errorrecovery strategies were unsuccessful,nurses described the need to correcterrors. Strategies related to correcting errorsinvolved 6 themes: persevering, being physicallypresent, reviewing or confirming the plan of care,offering options, referring to standards or experts,and involving another nurse or physician.

Persevering. In situations that required correct-ing an error, nurses commonly persevered, gave theerror their unrelenting attention, and followed upon the error. These strategies, which often involvedmultiple phone calls or pages to the patient’s physi-cian, were often but not exclusively discussed in thecontext of pain management and sedation. Theneed to persevere on basic patient needs such aspain medication clearly frustrated and challengedthe nurses yet at the same time compelled them todo whatever it took to meet the patient’s needs.Nurses’ examples included the following: “Callback,” “You push harder,” “If youhave to, keep doing it, chasing themdown, get in their face.” “I am con-stantly asking for the orders as I amgoing along, just preventing pain.That is all I was doing . . . trying toprevent . . . pain. Very, very difficult.”

Being Physically Present. Duringall phases of the error recoveryprocess, but particularly when issueswere not being addressed andneeded attention from other teammembers or the attending physi-cian, the nurses described theirphysical presence as an importantstrategy for correcting errors. When prior attemptsto interrupt or correct an error had failed, an impor-tant strategy appeared to be a face-to-face interaction

The ability ofnurses to inter-rupt an error was influenced by their experience and confidence.

The nurses’ comments sug-gested that situa-tions in which they could notinterrupt a serious errorwere rare.



with the physician. One nurse said, “Basically I standin the way, and I say ‘I have another major issue and

concern.’” Another nurse said, “Istepped in his way and I had to statevery firmly; usually I am soft spoken.”

Reviewing or Confirming thePlan of Care. A strategy critical to allphases of error recovery, particularlycorrecting errors, was knowing theplan of care and its rationale. Whennurses perceived an error in a treat-ment plan (error of commission)or that an aspect of patient care wasnot being adequately addressed(error of omission), they used thestrategy of clarifying the plan ofcare. Regarding strategies used to

correct error, focus group participants discussed theneed to clarify a plan of care with other team mem-bers respectfully, yet directly. For example, theyasked “Why are we doing this?” and “Why does thispatient need this?”

Offering Options. Nurses described correcting anerror, particularly an error related to omission ofpain medication or sedation, by offering alternativesto physicians or other providers. Similar to otherstrategies, offering options enabled nurses to carefor patients without embarrassing or disrespectinganother team member. One nurse explained, “I’ll say,‘Can we give her a one-time dose’ [pain medication]?”Another nurse gave this example: “I’ll ask them ifthey want to use lidocaine.”

Referring to Standards or Experts. Another groupof strategies described for correcting errors was torefer to critical care policies, hospital accreditationagencies, and unit-based or other standards. To cor-rect an error, nurses supported the need to alter aplan by citing other expert resources such as in-house

pharmacists and research articles.One nurse said, “I’ll quote journalarticles.” Another said, “I had to callthem [the provider] and show themthe Micromedex reference—thatthis was, in fact, the intended dose.”

Involving Another Nurse or Physi-cian. Another strategy discussed bythe nurses for correcting medicalerrors was asking senior cliniciansfor assistance or clarification. Whendescribing attempts to correct aproblem, nurses often referred to a

“chain of command” that they followed. To addresserrors or adverse events, the charge nurse and/orattending physician was identified by participating

nurses as most often helpful, but they did not alwaysturn to formal leaders. In fact, several participantscommented that they avoided some senior nursesor physicians who were perceived as overly criticaland intimidating. One nurse explained, “I just graba charge nurse and say something doesn’t look rightabout this. And from there we get the resident andfrom there the attending. It’s pretty stepwise, reallyeasy; just go up the ladder.” Another nurse said, “Ishould have called the physician, but I chose to callanother senior nurse.”

DiscussionThe results of this study provide preliminary

evidence of the role that critical care nurses play inrecovery of medical errors and in ensuring patientsafety. Several strategies reported in this study areidentical to those reported by emergency nurses9

and provide further empirical support for the nurse’srole in medical error recovery as proposed in theEindhoven near-miss model.6,15

Results of this study provide insight into themany strategies used by critical care nurses in errorrecovery. These strategies represent deliberate,thoughtful approaches that nurses use to keep theirpatients safe in environments recognized as high-riskand error-prone.1-5 These results, taken together withthose of other studies,2,3,5,7 provide evidence thatnursing vigilance prevents many potentially danger-ous situations from reaching and harming patients.Noteworthy in this study was the extent to whichnurses’ error-recovery strategies were crafted to pre-serve overall quality of patient care by respecting ateam members’ professional pride, protecting patientsand their families from undue anxiety, and avoidingprofessional discord. Although several of the strate-gies appear passive and nonassertive, the partici-pants viewed them as effective and consistent withtheir role as caregivers and teachers. The recoverystrategies ultimately adopted by nurses appear to bestrongly influenced by their experiences, both posi-tive and negative, with error recovery. A prior nega-tive experience, where a nurse was intimidated by aspecific individual, appears to have a profound neg-ative effect on the nurse’s willingness to engage inthe recovery process with the same individual again.

Many error recovery strategies reported in thisstudy were identified in a study of emergency nurses.9

For example, both critical care and emergencynurses identified errors by using the strategies ofsurveillance and double-checking. Yet the surveil-lance described by critical care nurses was relatedmore to individual patients, whereas emergencynurses described surveillance of the department as

In situations thatrequired correc-

tion, nurses commonly perse-vered, gave theerror their unre-lenting attention,and followed up

on the error.

Nursing vigilanceprevents many

potentially dangerous

situations fromreaching and

harming patients.



a whole. Both emergency and critical care nursesinterrupted medical errors by offering assistance,clarifying, and verbally interrupting.

Other strategies for error recovery differedbetween the 2 nursing groups, as expected becauseof the different goals and work processes of anemergency department and a critical care unit. Inemergency departments, for example, anticipationwas an important strategy for error identification,because nurses in the emergency department needto prepare for a fluctuating patient census and thepotential for unanticipated events. On the other hand,critical care nurses did not identify anticipation asa strategy and stressed the strategy of knowing thepatient, a strategy not identified by emergencynurses. Certainly, these results do not suggest thatemergency nurses do not value knowing the patientor that critical care nurses do not use anticipationas a strategy. However, these differences do suggestthat nurses in the 2 settings prioritize their use ofstrategies according to patients’ needs and environ-mental priorities.

Nurses play a role in improving patients’ out-comes.13,14 This role in patient outcomes has not beenspecifically studied in terms of nurses’ role in errorrecovery, but this area is clearly worth exploring.Studies on the type and frequency of errors in bothcritical care2,3,5 and emergency department settings8

indicate that many errors and near-misses are reportedby nurses. This study’s findings support the potentialof nurses to play a key role in reducing these errors.

The nurses in this study described several errorrecovery strategies, including surveillance and know-ing the patient, which have been recognized as inte-gral to patients’ outcomes.17-20 Surveillance, in relationto promoting and maintaining patient safety, isdefined as the purposeful, ongoing collection andanalysis of information about patients and theirenvironment.20 Nursing surveillance is a key factorin recognizing the development of complications,whereas lack of surveillance leads to “failure to res-cue.”13,14 The results of this study suggest that surveil-lance may also promote patient safety by playing arole in identifying errors.

Critical care nurses in this study frequently com-mented that “knowing” the patient, his/her familymembers, the plan of care, and the individualsinvolved in the patient’s care was imperative to pro-viding excellent care and to error recovery. This find-ing is consistent with the suggestion that “knowingthe patient” is important in the early recognition ofcomplications.21 Furthermore, “knowing the patient”has been espoused as integral to achieving benefi-cial outcomes for patients.18,19 Since this concept

includes knowing a patient’s experiences andresponse patterns, knowing the patient may resultin better informed decision making.18

The identification of knowing the patient as astrategy for error recovery has important implicationsfor interventions aimed at improving relationships,communication, and collaboration among nurses,patients, families, and providers. For example, involv-ing patients and their family members in multidisci-plinary rounds or holding routinepatient/ family meetings would be astrategy for knowing the patient fromthe perspective of the pivotal personswith a stake in the process. In addi-tion, nurses need easy and rapidaccess to information about thepatient’s history. In particular, criticalinformation that must be shared dur-ing handoffs must be standardizedand easily accessible to the nurse.

Although this study focused onerror recovery by staff nurses workingat the point of care, many participantsdiscussed the need to correct systemfailures by using appropriate commu-nication channels with administrativeand clinical leaders in their organiza-tion. For example, communication and collaborationfailures, inadequate pain and sedation management,and ethical issues were frequently used as examples oferrors that often required recovery strategies that werenot feasible for nurses while they were providing careat the bedside.

Limitations The preliminary, qualitative nature of this study

makes recommendations for practice premature,but the findings strongly suggest that nurses’ rolein error recovery deserves further investigation. Inaddition, this role should be recognized and sup-ported by nurse educators and administrators whoare preparing the nursing work force and designingsafe environments of care.

One limitation of this study is that the findingsmay have been biased by 3 of the 5 experts whoreviewed the content of transcripts, field notes,and anecdotal notes having been involved in astudy on strategies used by emergency nurses forerror recovery.9 More than half the recovery themesidentified in this study differed from the themesidentified in the earlier study, so the effect of thislimitation is minimal.

A second study limitation was the use of a con-venience sample. Given the study’s preliminary and

Many participantsdiscussed theneed to correctsystem failures byusing appropriate communicationchannels withadministrative andclinical leaders.



they might not be able to identify more errors ofcommission, particularly rule-based errors, thannovice nurses who may focus more on rules (eg,verifying patients’ identification). Research is neededon the types of errors most commonly recovered bynurses at various stages of experience and at whatpoint in the recovery process errors are recovered.

Error recovery may also be improved by techni-cal factors, for example, resources that enhanceaccess to information and ease of communicationbetween team members. Critical care units are con-sidered “complex sociotechnical systems” thatrequire unique products and services to run effi-ciently.22 Part of this efficiency involves the capacityto easily identify, interrupt, and correct errors asthey occur. Previous technical systems in criticalcare units were designed to track errors but not nec-essarily to respond in real time. Nurses’ error recov-ery is a real-time process. This new approach tosafety and quality will require interdisciplinarystudies and collaboration between nurses, otherhealth care professionals, human factors engineers,computer scientists, and more.23

Organizational cultures that support team-work and nonhierarchical ways of working wouldlogically promote nurses’ participation in the errorrecovery process. Nurses’ ability to identify, inter-rupt, and correct errors could also be influencedby other organizational factors such as staffingratios, resources (both human and technological),and work demands. A collaborative work environ-ment, coupled with a strong, safety-focused leader-ship team might improve error recovery, but theserelationships have not been studied.

Conversely, units that are not team orientedand a lack of resources might hinder nurses’ errorrecovery. A striking finding of this study was thatnurses’ ability and willingness to interrupt or cor-rect errors was affected by intimidation, regardlessof the nurses’ experience. Intimidation as a detri-ment to working relationships in health care is notnew,24 but its impact on nurses’ ability to safely carefor critically ill patients has not been studied.Nonetheless, an alarmingly high number of nursesreport difficulty voicing concerns when they identifyproblems with their patients.25

ConclusionOur results provide preliminary yet compelling

evidence of the unique role that critical care nursesplay in medical error recovery and preventingadverse events. Several strategies identified for errorrecovery by critical care nurses are the same as thestrategies reported by emergency nurses,9 but others

sensitive nature, we wanted to include nurses fromboth community and teaching hospitals who werewilling to participate. Although nurses’ error recov-ery strategies are likely to depend on their experi-ence and environment, these relationships have yetto be studied.

Last, the responses of the participants were basedon their recall of events and strategies. Some of theevents and strategies described occurred literallyhours before the focus group took place. Othersoccurred years before, for example, when the nursewas a novice in critical care. The emotional toll somenurses experienced and described may clearly havebiased their perspective.

Suggestions for Future ResearchResearch on nurses’ role in error recovery is in

its infancy. More information is needed on the suc-cess of strategies described by nurses and on nurseand environmental characteristics that support therecovery process.

Although nurses in this study described manysimilar strategies for error recovery, the effective-ness of those strategies in minimizing adverse

events is unknown. For example,strategies to interrupt errors wereoften described as being executedin ways that would “save face” andmaintain collegial relationships.Although this approach seems rea-sonable, it may delay interruptingerrors that need to be addressedmore directly to avoid potentialadverse outcomes. Additionally,this approach may be interpretedas passive aggressive and may per-petuate a view of nurses as profes-sionals unable to directly expresstheir concerns. Further study isneeded to identify approaches to

interrupting error that maximize positive outcomesand satisfaction for all involved parties.

The recovery process, according to the Eindhovenmodel,15 is influenced by human, technical, andorganizational factors, yet the impact of those factorson patients and nursing staff remains unclear. Humanfactors, namely, skill, knowledge, and rule-basederrors, play a critical role at the point of care andare of special significance to nursing. Althoughexperienced nurses seem likely to identify, interrupt,and correct more errors than novice nurses, thisassociation has not been studied. Experienced nursesmay be more capable of identifying errors of omis-sion and interrupting and correcting errors, but

Further study isneeded to iden-tify approachesto interrupting

error that maxi-mize positive

outcomes andsatisfaction for

all involved parties.



differ because of differences in settings and patients’needs. These findings provide further empirical sup-port for nurses’ role in medical error recovery asproposed in the Eindhoven model.

ACKNOWLEDGMENTSThe authors acknowledge Claire Baldwin for her edito-rial assistance and the University of MassachusettsAmherst Translation Services Department for assistancewith the transcription process.

FINANCIAL DISCLOSURESThis study was supported by grants from the GammaTau and Beta Zeta at Large chapters of Sigma Theta TauInternational.

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SEE ALSOFor more about medical error, visit the Critical CareNurseWeb site, www.ccnonline.org, and read the articleby Mattox, “Identifying Vulnerable Patients at Height-ened Risk for Medical Error” (April 2010).



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