SafetyDog

Missed Care: an error of omission

In Interuptions, Multitasking, Patient Safety on September 16, 2010 at 7:21 pm

According to Kalisch, Landstrom and Hinshaw (2009) one overlooked aspect in addressing patient safety is the concept of “missed care.” Missed care is classified in terms of error as an act of omission. Missed care is a concept that nurses are very well aware of but hesitant to bring into open discussion (Kalisch, et.al, 2009). Some reasons suspected for covering up these omissions are guilt, a feeling of powerlessness to correct the situation and fear of punishment for not completing tasks. There are even reports of false documentation to hide these errors of omission because of fear of retribution and an acceptance of this being the norm (Kalisch, et al, 2009). Kalisch, et al, (2009) liken this hiding of these errors to the hiding of medication errors and near misses that was prevalent prior to the patient safety movement…. more
Through a qualitative study, Kalisch, Landstrom & Williams et al, (2009) found these errors of omission tend to result from staffing ratios, time constraints (eg. the task takes much longer than expected), teamwork issues, lack of delegation skills, denial of these omissions being errors and a sense of habit when these conditions occur frequently. Staff are forced to make choices when faced with multiple demands and limited resources. These situations may be continuous in a shift that is understaffed or these may occur during a shift with adequate staffing when there is a sudden increase in the demand for care because of unanticipated admission/discharge activity or a change in a patient’s status.
Omissions of care tend to occur in the following categories: ambulation, turning, delayed or missed feedings, patient teaching, discharge planning, emotional support, hygiene, monitoring of intake and output and assessments (Kalisch, et. al, 2009).
While these errors of omission have great implications for patient safety they have also been shown to affect nurse job satisfaction and turnover rates (Kalisch, et al., 2009). Similar to other professions such as teaching, new graduates are more at risk to leave the profession altogether if their first job experiences involve this type of environment (Kalisch, et. al, 2009).

It is clear from the work done by Kalisch, et al. (2009) that errors of missed care need to be examined from a safety and quality perspective in the same way that medication errors are reported and addressed. Staff would benefit from teamwork training and well as delegation guidelines. Teams of SWAT-team like nurses should be available to help units for short periods of time when there is a sudden increase in care demands. Shifts should be understaffed for as little time as possible. There should be a simple way to report errors of missed care that is not time consuming. Examination of all processes related to these omissions might reveal supply or workflow issues that would prevent missed care events. Staff might also benefit from some sort of algorithm that standardizes or provides a framework for the prioritizing of care.
All comments and suggestions on this concept of missed care errors are welcome. Other than Kalisch, et al, (2009) there is not much in the literature on this important topic for patient safety, quality and satisfaction.

Dr Kalisch’s bio
Please read her articles on the concept of missed care and multitasking and many other pertinent safety topics

Kalisch’s view of missed care from the other side as a patient herself..a must read for healthcare providers. Unfortunately you need to be a Sigma Theta Tau member to read this in its entirety. It supports her theories with personal experience.

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