A retrospective audit of nursing-related morbidity recorded in a state hospital in KwaZulu-Natal.
Spumelelo P Nyide, Petra Brysiewicz, John Bruce and 1 others
PMID 31038327WHAT IT FOUND
Surgical patients had 461 nursing-related morbidities in 12 444 admissions, 3.7%.
Drug errors were most common, then intravenous lines, drains and tubes. Retrospective reporting likely missed some events.
Key findings
01During 12 444 surgical admissions, 461 nursing-related morbidities were recorded, an incidence of 3.7%.
02Drug and medication errors were the most common category (167 cases, 36%), and drug omission was reported in 123 cases (74% of drug errors).
03Adjunct management errors were second most common (130 cases, 28%), with intravenous lines accounting for 68 cases (52% of that category).
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
Read the rest of this summary
You get three full summaries a month, free, and we do not ask for a card. Search, the TL;DRs and your library stay unlimited either way.
What it does not show
The audit was retrospective, so the quality of documented data may have affected the results. Underreporting may have occurred in the first 2 years, when the registry had just been initiated. Paediatric patients were excluded because of poor documentation and underreporting. The study was conducted in one tertiary hospital, so it may not represent other services. Different people documented data at different times, which could introduce information bias. The sharp rise in documented morbidities in the last year may reflect greater familiarity with reporting rather than a true increase.
The easy way to misread this
Do not treat the 3.7% incidence as the true rate of nursing-related harm. Paediatric data were excluded, the audit was retrospective, and underreporting in the first 2 years was possible because the registry had just been initiated.