Learning from stories—a pathway to patient safety

AORN Journal,  July, 2006  by Suzanne C. Beyea,  Aileen Killen,  G. Eric Knox

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MOST NURSES can tell a story about a remarkable clinical situation--one in which everything went right and a patient who might have died was saved. Other nurses have a story in which events did not go as planned, and a patient suffered an adverse outcome or an error was prevented in the nick of time (ie, a near miss or good catch). These stories may be described as case studies, narratives, or exemplars.

Storytelling has a rich tradition in educating nursing students, orienting new staff members, and developing competencies, and stories often are more helpful in teaching a concept than a classic lecture. Stories help listeners remember facts and details that otherwise might be forgotten. When events are told in the form of a story, they catch our attention and leave a lasting memory.

The first nursing stories many nursing students hear are about an unexpected cardiac arrest, a precipitous birth, or a patient who experienced flash pulmonary edema. When a student graduates from an entry-level program, he or she may never have seen a cardiac arrest, except as portrayed on television; nevertheless, novice nurses listen carefully to stories about code situations told by more experienced nurses. These stories paint a picture of events that have led to emergent situations and provide valuable lessons about how to recognize life-threatening symptoms and respond effectively.

Sharing Our Mistakes

PATIENT SAFETY in the OR is enhanced by telling stories that teach others about our mistakes as well as our successes. One story all perioperative clinicians should know involves the events that led to the death of Ben Kolb, a 7-year-old boy who inadvertently received an extremely concentrated form of epinephrine as a local anesthetic. (1) The epinephrine had been intended for use as a topical application instead of for parenteral administration. This error and the organizational conditions that produced it resulted in the child's eventual death. Ben's death occurred because medications on the surgical field were not labeled and were misidentified. This case was reported by the major television networks and by a number of perioperative nursing publications. Ben's parents have told the story of the events leading up to his death in hopes of preventing similar errors.

A nurse may tell of the day a major artery was nicked during laparoscopic surgery or a patient was moved into the wrong surgical suite. Many perioperative nurses have heard stories about retained instruments or sponges or wrong-site surgery. These narratives teach us about the hazards, unsafe conditions, and accident-producing contexts that exist within specific practice environments. They may suggest strategies or offer warnings to help prevent a recurrence. For example, when a student nurse hears a story of a retained instrument, it emphasizes the importance of performing counts and ascertaining their accuracy. Stories often help nurses remember critical elements of safe practice and, like many childhood stories, help the listeners learn valuable lessons. Stories thus become gifts to our colleagues that assist all of us in our primary work--creating safety.

Imagine a nurse who goes to the holding area and cannot find her perioperative patient. Panicked, the nurse looks in each operating suite. With luck, she finds her patient in the wrong room being prepped for the wrong surgery. She brings this error to the attention of the other staff members, who are relieved that the error was detected. This story reminds everyone who hears it about the importance of checking a patient's name band and verifying identity before surgery. More importantly, the story allows everyone to consider the human and system factors that created the conditions that allowed the error to occur. Telling such a story is more powerful than providing staff members with a copy of the policy and procedure related to patient identity. Furthermore, a story such as this one identifies potential risks and reinforces how close each clinician is to making a serious error.

Making Stories Specific

IN TRYING to better understand how medical errors occur, many researchers have tried to quantify the number and types of medical errors. These efforts have helped health care professionals appreciate the magnitude of medical errors and better understand what types of errors occur. It is the case descriptions of errors, however, that often provide the greatest understanding and learning, as well as illustrating that errors most often occur as a result of multiple factors rather than isolated events.

Stories can provide rich descriptions that help nurses and other clinicians understand the circumstances and system vulnerabilities that contribute to either a positive or negative outcome. They also can provide important details about a clinical situation and the involved clinicians' interactions.

A secondary analysis of the United States Pharmacopeia's national Medmarx database demonstrates that numerous medication errors occur in perioperative settings. (2,3) The case studies, however, provide the detailed descriptions required to explain the specific nature and themes associated with the errors. Each case description contributes to a clearer understanding of the circumstances leading to a medication error. The case descriptions also support the ability to detect trends and themes that allow specific practice recommendations.