Promoting patient safety by monitoring errors

A view from the middle

Michal Tamuz, Cynthia Russell, Eric J. Thomas

    Research output: Chapter in Book/Report/Conference proceedingChapter

    Abstract

    Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a culture that fosters reporting of errors. Their staff nurses expect the managers to support them after errors occur. Drawing on interviews with 20 nurse managers from three tertiary care hospitals, the study identifies key exemplars that illustrate how managers monitor nursing errors. The exemplars examine how nurse managers: (1) sent mixed messages to staff nurses about incident reporting, (2) kept two sets of books for recording errors, and (3) developed routines for classifying potentially harmful errors into non-reportable categories. These exemplars highlight two tensions: the application of bureaucratic rule-based standards to professional tasks, and maintaining accountability for errors while also learning from them. We discuss how these fundamental tensions influence organizational learning and suggest theoretical and practical research questions and a conceptual framework.

    Original languageEnglish (US)
    Title of host publicationPatient Safety and Health Care Management
    EditorsGrant Savage, Eric Ford
    Pages69-99
    Number of pages31
    DOIs
    StatePublished - Aug 15 2008

    Publication series

    NameAdvances in Health Care Management
    Volume7
    ISSN (Print)1474-8231

    Fingerprint

    Nurse Administrators
    Physiologic Monitoring
    Patient Safety
    Nurses
    Learning
    Social Responsibility
    Risk Management
    Tertiary Healthcare
    Tertiary Care Centers
    Nursing
    Interviews
    Research

    All Science Journal Classification (ASJC) codes

    • Health Policy

    Cite this

    Tamuz, M., Russell, C., & Thomas, E. J. (2008). Promoting patient safety by monitoring errors: A view from the middle. In G. Savage, & E. Ford (Eds.), Patient Safety and Health Care Management (pp. 69-99). (Advances in Health Care Management; Vol. 7). https://doi.org/10.1016/S1474-8231(08)07004-3

    Promoting patient safety by monitoring errors : A view from the middle. / Tamuz, Michal; Russell, Cynthia; Thomas, Eric J.

    Patient Safety and Health Care Management. ed. / Grant Savage; Eric Ford. 2008. p. 69-99 (Advances in Health Care Management; Vol. 7).

    Research output: Chapter in Book/Report/Conference proceedingChapter

    Tamuz, M, Russell, C & Thomas, EJ 2008, Promoting patient safety by monitoring errors: A view from the middle. in G Savage & E Ford (eds), Patient Safety and Health Care Management. Advances in Health Care Management, vol. 7, pp. 69-99. https://doi.org/10.1016/S1474-8231(08)07004-3
    Tamuz M, Russell C, Thomas EJ. Promoting patient safety by monitoring errors: A view from the middle. In Savage G, Ford E, editors, Patient Safety and Health Care Management. 2008. p. 69-99. (Advances in Health Care Management). https://doi.org/10.1016/S1474-8231(08)07004-3
    Tamuz, Michal ; Russell, Cynthia ; Thomas, Eric J. / Promoting patient safety by monitoring errors : A view from the middle. Patient Safety and Health Care Management. editor / Grant Savage ; Eric Ford. 2008. pp. 69-99 (Advances in Health Care Management).
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