Rules Outside the Rules Rules outside the rules.pdf
This qualitative study by Baker (1997) opens up the dialogue on the reporting of errors by nurses and reveals tacit rules that prevent error reporting. Baker studies the tacit rules related to medication administration in an effort to describe how nurses explain away and therefore do not report error. This study has major implications on learning for the novice nurse, because the tacit rules are not written anywhere, and cannot be memorized or studied, much less followed without an experienced understanding of the patient, the medication, and the patient’s response to the medication, and a full understanding of the context and situation. Baker explores these tacit rules through her observations and interviews. They would be impossible for a student to know and understand. To the observer, it appears that an error is being made, but to the experienced nurse, it is not seen or described as an error, therefore it is not reported. Tacit rules add to the complexity of healthcare and the challenge of learning a practice. The ones discovered and described by Baker’s study are related to medication administration only and by no means exhaust the number of tacit rules that exist for nurses in their work setting.
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Unreported Errors in the ICU Unreported Errors in ICU.pdf
This case study about errors is written by an ICU nurse. It shows how a nurse may get so used to the system not working that they no longer are able to identify errors as errors, therefore leaving many errors un reported. This is a great article to spark classroom discussion on errors.