Preventing a Cascade of Nursing Actions That Can Lead to Errors

April 1, 2021
April 1, 2021

Equipping your care providers with a quality residency program at the start of their careers is one way to prevent an unfortunate combination of actions from even beginning, reducing potential adverse patient outcomes. In a recent conversation, Kimberly Sulger, HealthStream’s AVP of Clinical Solution Success Management, shares her perspective on why mistakes are so easily made and how hospital onboarding programs play a vital role in reducing errors. Here’s an excerpt from the article based on this interview.

Stopping Serious Nursing Errors before They Start

Sulger suggests that the first step in preventing adverse patient events is to ensure that there is a culture of safety in hospitals and organizations. “This is important to ensure that events do get reported and aren’t always considered punitive. Of course there will be ramifications for errors, but adverse events need to be viewed as both a learning opportunity and a new opportunity to use a systems approach to patient safety and error prevention.”

It Typically Takes More Than One Person to Make a Serious Error

Errors are almost never the result of one person’s carelessness, Sulger emphasizes. “There’s almost always some cascade of actions that leads up to something that is larger than the sum of all the parts,” says Sulger. “Using a systems approach to put processes in place, considering all the downstream ramifications, and individually assessing and developing the clinical competency of nurses are all key in stopping that cascade of adverse events.”

Developing Critical Judgment Is Key to Preventing Adverse Events

According to Sulger, facilitating the development of critical judgment is one of the most important ways to prevent adverse patient events. Sugler explains, “Clinical judgment cannot be learned in school, by sitting in front of a computer, or while reading a book. It is learned through the combination of experience, reflection, and time. Judgment is one of the key domains of competency, and arguably the most important, but it is the last to be developed.” Sulger emphasizes that mentorship programs with preceptors who engage in reflective practice and facilitate all the aspects of competency development with novice nurses are critical to the development of critical judgment.

The full article also includes:

  • What Qualifies as an Adverse Patient Outcome?
  • Failure to Integrate the Entire Picture Results in Mistakes
  • Onboarding Impacts Outcomes


Download the article here.