The TERCAP Tool: Investigation of Nursing Errors in Greek Hospitals

Abstract

Background: Errors are a common occurrence in all healthcare settings, and the safety of patients is a critical concern that involves multiple factors, including the complex and demanding nature of nursing practice. Nurses, due to their continuous and direct patient care, play a pivotal role in ensuring patient safety. This cross-sectional study aimed to investigate the factors that contribute to errors from the perspectives of nurses in Greek hospitals, with a focus on understanding the challenges they face in their daily practice. Methods: Clinical nurses willingly and anonymously filled out a specific structured questionnaire, the Taxonomy of Error, Root Cause Analysis, and Practice-responsibility (TERCAP) tool that describes the conditions under which an error during clinical practice occurred. The study method included convenience sampling. After obtaining permission, questionnaires were distributed to hospital departments. To accommodate pandemic-related restrictions, an electronic version of the questionnaire was also created for distribution and collection. Analysis of data was accomplished via SPSS 26.0. Results: Five hundred and ninety-seven clinical nurses participated anonymously, reporting errors in almost seven out of ten cases, often attributing them to high workload and staff shortages. Errors were commonly reported during different shifts in this study. Factors such as assigning significant responsibilities to inexperienced staff and inadequate implementation guidelines were highlighted. Conclusions: The in-depth study of nursing errors provides a nuanced understanding of their causes by categorizing them based on various factors. It emphasizes the complexity of challenges and the need to integrate systemic, clinical, and individual factors into intervention strategies, including medication protocols, ongoing training, clear communication, administrative support, and fostering an open communication culture.

1. Introduction

Errors in the nursing profession are an unfortunate reality that arises from a complex interplay of various factors. These errors are not only a result of individual mistakes but also reflect systemic issues within healthcare organizations. Structural deficiencies, such as inadequate staffing levels, poorly designed workflows, and insufficient resources, contribute significantly to the prevalence of nursing errors. Additionally, inherent cognitive biases and the demanding nature of the nursing profession—characterized by high work intensity and rapidly changing conditions—further exacerbate these challenges [1].

In our country, the fast-paced and demanding nature of the healthcare work environment significantly intensifies the pressure on nurses, which in turn elevates the risk of errors. The intense workload, coupled with constant time constraints and high expectations, creates a setting where mistakes are more likely to occur. It is essential to understand not only the characteristics and frequency of these errors but also their underlying causes to develop effective strategies for mitigating them. By comprehensively analyzing these factors, we can create an environment that fosters continuous improvement and upholds patient safety as a top priority. Effective process control and vigilant supervision are crucial elements in tackling these challenges. Implementing robust systems for monitoring and controlling workflows, alongside providing ongoing training and support, can help enhance the overall quality of healthcare services and reduce the likelihood of errors [1].

The role of nurses is integral to patient care, as they are frequently the primary caregivers who engage in daily interactions with patients. Their close proximity to patients means they are in a position to directly influence patient outcomes and well-being. Consequently, any errors in nursing practice can have profound and potentially severe consequences for individuals who are in vulnerable or critical conditions. Given the gravity of these potential outcomes, nurses are highly motivated to prevent situations that might lead to negative repercussions or emotional distress for patients. The serious implications of nursing errors necessitate a focus on improving practices and procedures to ensure that patient care is delivered safely and effectively [2]. Ensuring that nurses are well supported and equipped to manage the pressures of their roles is essential for minimizing errors and enhancing patient care quality.

Numerous scientific, ethical, and legal publications have explored the concept of errors in healthcare, each offering different definitions and perspectives. Despite this extensive discourse, there remains a lack of precise and universally accepted definitions and understanding of what constitutes a nursing error [3]. This gap in professional understanding underscores the need for further investigation. This study seeks to address this gap by identifying and examining the mistakes that occur in routine nursing care. By investigating these errors from the perspectives of nurses working in Greek hospitals, this study aims to uncover the factors contributing to these mistakes and to provide insights that can lead to improvements in patient safety and the overall quality of nursing practice. Through this detailed exploration, this study hopes to contribute to the development of strategies and interventions that can mitigate errors and support nurses in delivering safe and effective care.

2. Materials and Methods

2.1. Study Design

A cross-sectional quantitative study was conducted to identify and understand the current state or distribution of characteristics within a nursing population regarding errors. By providing a snapshot of various factors at a single point in time, they help recognize trends and guide further research. Additionally, it is less time-consuming and less expensive compared to other research methods. This study was carried out between November 2020 and November 2023, relying on voluntary and anonymous survey responses. Approval for this study was granted by the Ethics Committee of the University of West Attica (52654—20 July 2020) and the scientific councils of all collaborating Greek hospitals. Questionnaires were distributed to hospitals’ departments after permission was granted. To adapt further to the hospitals’ pandemic-related restrictions throughout the study duration, an electronic version of the questionnaire tool was developed for distribution and collection purposes too.

Convenience sampling was chosen as it allowed easy access to the desired population across various nursing departments. While this approach has certain advantages, such as ease of access and cost-effectiveness, it also presents several limitations that should be considered. One major limitation is the potential for sampling bias. Since participants are not randomly selected, the sample may not accurately represent the broader population, which can affect the generalizability of the findings. This means that the results might not be applicable to all groups outside of the study sample.

Additionally, convenience sampling may lead to an overrepresentation or underrepresentation of certain characteristics within the sample, further skewing the results. In this study, the convenience sample was selected by recruiting participants from specific hospitals, by selecting individuals who were available and willing to participate during the study period, and by using social media platforms to reach out to potential respondents. This method was chosen due to time and area constraints (especially during the pandemic period), and the need for a quick preliminary understanding. Despite these limitations, convenience sampling can still provide valuable insights, especially in exploratory research or when studying hard-to-reach populations. It is important to acknowledge these limitations transparently and consider them when interpreting the results.

2.2. Participants

The sample consisted of 597 nurses who were working in a hospital environment at a specific point in time and geographic location. Using G*Power 3.1 analysis, it was calculated that with a sample of 590 nurses, the study would have 99% power. This descriptive study encompassed participants from various educational backgrounds within the nursing field, including university-trained nurses, those from technological institutions, and assistant nurses from secondary schools. These participants were employed in general hospitals across Greece. More precisely, questionnaire distribution included departments such as pathology, surgery, intensive care units (ICUs), respiratory clinics, pediatric departments, and oncology units in five tertiary hospitals.

2.3. Instruments

The research instrument comprised two sections:

• Demographic information, including inquiries about participants’ gender, age, marital status, educational background, and specifics regarding their work department (such as inpatient, outpatient, operating, oncology, or other), along with the duration of their tenure in a particular unit;
• The Taxonomy of Error, Root Cause Analysis, and Practice-responsibility (TERCAP):

The tool to estimate risk of clinical adverse events in nursing, the TERCAP tool, is a structured instrument designed to evaluate and analyze the risk factors associated with nursing errors and clinical adverse events. Benner et al. [4] developed this tool to enhance patient safety and improve nursing practices. TERCAP provides a systematic approach to identifying and addressing factors that contribute to nursing-related errors. The primary aim of TERCAP is to assess the likelihood of adverse events in nursing care by evaluating various risk factors. It helps healthcare organizations understand where vulnerabilities exist within their nursing practices, enabling targeted interventions to improve patient safety.

TERCAP consists of several key components:

Risk Factors: The tool evaluates a range of risk factors, including environmental conditions, staffing levels, communication practices, and workflow processes. It examines how these factors may influence the occurrence of errors and adverse events.

Survey Items: It includes a series of questions or statements related to different aspects of nursing practice. Respondents, typically nursing staff or managers, rate these items based on their experiences and observations.

Scoring System: TERCAP uses a scoring system to quantify the level of risk associated with each factor. This scoring helps in identifying areas with higher risk and prioritizing interventions.

Healthcare organizations employ TERCAP to achieve the following:

Assess Risk: By evaluating responses, organizations can identify potential areas of concern related to nursing errors and adverse events.

Analyze Patterns: The tool helps in recognizing patterns or trends in nursing practices that may contribute to errors.

Implement Improvements: Insights gained from TERCAP enable the development of targeted strategies and interventions aimed at mitigating identified risks and enhancing patient safety.

Development and Validation:

The TERCAP tool was developed based on extensive research and expert input from the fields of nursing and patient safety. It has been validated through various studies to ensure its reliability and effectiveness in predicting and analyzing risk factors related to nursing errors. In summary, TERCAP is a valuable tool for healthcare organizations seeking to improve patient safety by systematically assessing and addressing risks associated with nursing care. Its structured approach and comprehensive evaluation criteria make it an essential component in the ongoing effort to enhance nursing practice and prevent adverse events.

This section aimed to gather descriptive data on nursing practice breakdowns from various nursing boards. It presents a range of classifications rooted in principles of exemplary nursing practice, encompassing areas like safe medication administration, documentation, surveillance, prevention, intervention, clinical reasoning, interpretation of orders, and professional responsibility/patient advocacy [4]. It is important to note that the questionnaire underwent validation in Greek, because there was no previous use, through double translation and assessment via test–retest performance. Since all participants were Greek citizens, translating the questionnaire into Greek was deemed the appropriate method to ensure comprehension. Specifically, a specific question within the demographic section asked whether Greek was the participants’ mother tongue, with 100% affirmative responses. Written informed consent was obtained from all study participants (in cases where natural distribution was feasible). In the event of electronic completion, participants were required to select “Agree” or “Not agree” to proceed or discontinue with the rest of the research tool.

3. Results

In this study, 597 nurses participated in completing the questionnaire. The sample consisted of 86.6% females and 13.4% males. According to data, 69.7% of the sample (n = 416) mentioned an error occurrence in the working place, and additionally, 48.5% (n = 198) of them were responsible for it. Regarding age distribution, 39% were nurses aged 22–35 years, 36% were aged 36–45 years, 22.9% were aged 46–55 years, and 2.2% were over 56 years old. Married nurses comprised 45.8% of the sample, while 50.1% had children. The number of children of the participants had a mean of 1.9 with a standard deviation (SD) of 0.7. Cohabiting nurses accounted for 5.1% of the sample, and 5.1% were separated. Regarding education, 83.4% of the nurses had tertiary education degrees. Among them, 40.1% held postgraduate or doctoral degrees or were in the process of obtaining them. Additionally, 15.6% were graduates of vocational nursing schools or secondary education. Furthermore, 9.4% of the nurses had completed a nursing specialty. Concerning economic status, 45.6% reported a monthly income of EUR 500–1000, while 50.8% had incomes of EUR 1001–1500 (

Table 1. Participants’ demographics.

		n	%
Gender	Male	79	13.4
	Female	512	86.6
Age	22–35	232	39
	36–45	214	36
	46–55	136	22.9
	56+	13	2.2
Marital status	Single	235	39.6
	Married	272	45.8
	Cohabiting	30	5.1
	Divorced	55	9.3
	Widowed	2	0.3
Children	No	298	49.9
	Yes	299	50.1
Educational level	University graduate (Bachelor’s, Master’s)	258	43.3
	Vocational school graduate	44	7.4
	Secondary education graduate	49	8.2
	Postgraduate/doctoral studies	241	40.1
	Other	4	0.7
Specialty holder	No	540	90.6
	Yes	56	9.4
In which of the following categories does your monthly net income fall?	EUR 500–EUR 1000	272	45.6
	EUR 1001–EUR 1500	303	50.8
	EUR 1501–EUR 2000	19	3.2
	EUR 2001 and above	2	0.3
Does your income include any additional employment?	No	518	86.9
	Yes	78	13.1
Is Greek your native language?	No	23	3.9
	Yes	565	96.1

).

The percentage of graduate nurses was 83.6%, some of whom (20%) held positions of high administrative responsibility in the nursing hierarchy, such as supervisors, department heads, and directors, and 16.1% were enrolled nurses. The median number of beds covered by participants’ work units was 13 (range: 7–21), and the total number of beds in the work unit was 18 (range: 9–31). In 69.7% of the participants, an error occurred in their workplace, with 48.5% of these errors being attributed to themselves (personal responsibility) and 74.5% to another colleague in the clinical setting. At the time when the error occurred in the workplace, the mean professional experience of the participants was 5.53 years, with a standard deviation (SD) of 6.48 years. Additionally, 39.6% of the errors occurred during the morning shift, 35.7% during the afternoon shift, and 17.3% during the night shift. Approximately eight out of ten of the participants (85.8%) reported that they were not working in a temporary position when the error occurred, while only 17.3% stated that they were working in a temporary position.

Of the total sample, 27.5% had at least 20 patients per nurse under their responsibility when the error event occurred. Furthermore, 23.2% of participants had been called upon by nursing management for additional guidance on proper implementation of nursing care in daily clinical practice, and 5.9% had some repercussion from management in their work following the error event. In response to an open question regarding nursing administrative actions towards the nurse who committed the error, nurses reported that there was a change in work department, prohibition of patient care by the nurse who committed the error, training of the nurse to improve skills for error prevention, reprimand, and supervision with oversight in the nurse’s subsequent work path.

Additionally, in 2.4% of participants, there was some report against them for issues related to the proper implementation of nursing care in daily clinical practice to nursing management prior to the occurrence of the error event, and only in 0.3% was there any involvement in a criminal event in the past outside the workplace. Data regarding the error that occurred in the participants’ workplace are presented in

Table 2. Data regarding the error.

		n	%
What shift were you working at the time when the error occurred?	Morning (7–15)	144	39.6
	Evening (15–23)	130	35.7
	Night (23–7)	63	17.3
	I don’t remember	21	5.8
	Other	6	1.6
Do you work in a temporary position (e.g., assisting in another department, taking care of a patient instead of another nurse)?	No	321	85.8
	Yes	40	10.7
	I don’t know	13	3.5
How many patients were under your care at the time the incident occurred?	Up to 3	80	21.6
	4–15	87	23.5
	16–20	53	14.3
	20 and more	102	27.5
	I don’t know	49	13.2
Have you been called upon by nursing management (supervisor, head nurse, director) regarding matters of proper implementation in daily clinical practice?	No	289	76.3
	Yes	88	23.2
	I don’t know	2	0.5
Was there any impact on your work following the occurrence of the error?	No	354	94.1
	Yes	22	5.9
Was there any report against you regarding issues of proper implementation in daily clinical practice to nursing management prior to the occurrence of the event?	No	353	93.4
	Yes	9	2.4
	I don’t know	16	4.2
Have you been involved in a criminal event in the past?	No	371	98.1
	Yes	1	0.3
	I don’t know	6	1.6

.

The mean age of the patients involved in the error was 53.5 years old (SD = 27.3 years), with 61.5% of them being male. The initial diagnoses of the patients were malignancies/tumors (23.3%), cardiovascular diseases (21.7%), and respiratory conditions (21.8%). Additionally, 5.3% of the patients at the time of the error experienced difficulty in communication/understanding, 6.3% exhibited agitation/aggressiveness, and 5.6% experienced sensory loss (hearing, touch, vision).

The error primarily occurred in the patient’s room (22.4%) or in the ICU (9.9%). Complications after the error occurred in 103 patients (26.9%). In 66% of cases, the error resulted in minor negative impact on the patient, in 8% the patient died or could have died due to the error, and in 7.3% there was a serious complication. According to the participants (

Table 3. System factors that contributed to the occurrence of the event, ranked in descending order.

Factors within the System That You Believe They Contributed to the Occurrence of the Event	n	%
Lack or inadequacy of orientation/training	138	34.6
Lack of ongoing training	136	34.1
Lack of a common line for dispute resolution	103	25.8
Interdepartmental communication breakdown/conflict	95	23.8
Shift change (patient hands-off) time	84	21.1
Dysfunction of communication system equipment	76	19.0
Patient aliasing	73	18.3
Patient misidentification	71	17.8
None of the above	66	16.5
Patient transfer (hands-off)	46	11.5
Other	36	9.0
Inaccessible medical record	36	9.0
Malfunction of electronic system	21	5.3

), the main factors believed to contribute to the occurrence of the error were lack or inadequacy of orientation and training for new hires (34.6%), lack of ongoing education (34.1%), and lack of a common protocol for dispute resolution (25.8%).

Of the total percentage of participants, 23.8% reported that the error was due to a breakdown in interdisciplinary communication among nurses, shift changes (21.1%), malfunction of communication system equipment (19%), patient name confusion (18.3%), and failure to identify the patient (17.8%).

The high workload of staff and the continuous staff shortage were the main factors associated with management and errors, with percentages of 82.9% and 74.6%, respectively. Additionally, assigning higher-responsibility tasks to inexperienced staff (51.3%), inadequate guidelines for implementation (38.7%), insufficient support from nursing management (34.9%), lack of support from supervisors (31.9%), unclear orientation and ambiguous responsibility boundaries (31.7%), inadequate supervision (24.1%), and inadequate patient classification system to support proper staffing placement in appropriate responsibility positions (19.3%) were reported by participants as contributing to errors from a management perspective. Furthermore, in response to an open question about management factors, nurses cited lack of experience of supervisors on the subject matter to provide proper guidance on error handling, lack of interest from management in proper and rational education, and absence of ongoing training.

The main alternative and aggravating factors responsible for the occurrence of error events were reported to be the ineffective support of nurses in “under pressure” care situations at a rate of 64.3%, and the lack of a specialized nursing system at a rate of 59.5%. Almost half of the participants (49.9%) mentioned ineffective distribution of tasks to nurses for the safe care of patients, 24.1% reported a lack of mindset for adequate collaboration with laboratories, radiology departments, pharmacies, or other departments as additional catalytic factors contributing to errors, and 21% emphasized the lack of adequate response to worker rights for providing sufficient care as an additional catalytic factor in error occurrence. Additionally, in response to an open question regarding alternative factors contributing to error occurrence, nurses cited the continuous lack of nursing staff and workload. Factors related to management and the occurrence of error events, as well as alternative and catalytic factors responsible for error occurrence, are detailed in

Table 4. Factors related to management and the occurrence of error incident, along with alternative and aggravating factors responsible for creating the error.

		n	%
Which factors do you believe are related to management and the occurrence of the error event?	High workload of staff	330	82.9
	Continuous staff shortage	297	74.6
	Assignment of tasks to inexperienced personnel	204	51.3
	Inadequate guidelines for task implementation	154	38.7
	Lack of support from nursing management	139	34.9
	Lack of support from supervisor	127	31.9
	Unclear orientation and jurisdictional boundaries	126	31.7
	Inadequate supervision	96	24.1
	Inadequate patient classification system to support appropriate staffing placement	77	19.3
	None of the above apply	10	2.5
	Other	3	0.8
Alternative and supportive factors believed to contribute to the creation of the error incident	Ineffective support of nurses in “high-pressure” care situations (emergency needs in relevant departments)	254	64.3
	Lack of specialized nursing system	235	59.5
	Ineffective distribution of work to nurses for safe patient care	197	49.9
	Lack of mindset for adequate collaboration with laboratories/radiology department/pharmacy or any other department	95	24.1
	Inadequate response to employee rights for adequate care provision	83	21.0
	None of the above apply	26	6.6
	Other	4	1.0

in descending order.

The primary environmental factors responsible for an error included the frequent distraction of nurses by patient visitors during high-concentration tasks and interventions from visitors (56.7%), the interruption of nursing tasks due to multiple urgent patient events in clinical care (51.4%), and the lack of appropriate materials and equipment during the application of therapeutic nursing interventions (46.6%). Additionally, environmental factors reported by participants included increased noise (26.4%), equipment misuse (16.9%), inadequate lighting (14.9%), misleading labels (excluding medications) (14.1%), physical environmental hazards (13.1%), and situations where the hospital is in a state of emergency as reported by 10.6% of nurses. In response to an open question about environmental factors, nurses also mentioned increased room temperature, poor organization of their workspace and facilities, and frequent interruptions and interventions by healthcare and non-healthcare personnel. The environmental factors responsible for an error are detailed in

Table 5. Environmental factors responsible for the error (in descending order).

Environmental Factors	n	%
Frequent interruptions and interventions by visitors	225	56.7
Multiple urgent situations	204	51.4
Lack of materials and equipment	185	46.6
Increased noise	105	26.4
Equipment misuse	67	16.9
Inadequate lighting	59	14.9
Similar/misleading labels (non-pharmaceutical)	56	14.1
Natural environmental hazards	52	13.1
Hospital in a state of emergency (code)	42	10.6
None of the above	40	10.1
Other	3	0.8

, in descending order.

Of the total sample, 33.3% stated that the physician contributed to the occurrence of the error through communication, while 32.6% (n = 126) reported that another nurse contributed to the occurrence of the error, and 31% reported that the charge nurse contributed to the occurrence of the reported mistake (

Table 6. Other factors that contributed to the occurrence of the event.

		n	%
Other healthcare team members who contributed to the event occurrence through their communication	Responsible nurse	120	31.0
	Physician (attending, resident, or other)	129	33.3
	Pharmacist	11	2.8
	Another nurse	126	32.6
	Moving/auxiliary staff	39	10.1
	Another healthcare professional	21	5.4
	Health sciences student/trainee	14	3.6
	Nursing assistant during medication administration	31	8.0
	Other supportive staff	8	2.1
	The patient themselves	36	9.3
	Patient’s family/friends	24	6.2
	Unlicensed auxiliary staff (trainees)	10	2.6
	None of the above apply	63	16.3
	Unknown	50	12.9
	Other	0	0.0
Personnel issues that you believe they contributed to the occurrence of the event	Lack of supervision/support from management	61	15.8
	Lack of experienced nurses	185	47.8
	Lack of support from nursing staff	95	24.5
	Lack of secretarial support	28	7.2
	Lack of support from another healthcare team	37	9.6
	None of the above apply	83	21.4
	I don’t know	42	10.9
	Other	4	1.0
If other, specify:	Lack of communication	1	0.2
	Lack of organization	1	0.2
	Inadequate communication	1	0.2
Healthcare team	Conflicts with staff from other clinics	47	12.4
	Failure of healthcare team communication	172	45.3
	Lack of interdisciplinary care planning	93	24.5
	Intimidating/threatening behavior	85	22.4
	Absence of patient participation in healthcare planning	56	14.7
	Care obstructed by regular or unwritten rules limiting communication	86	22.6
	Majority of staff have not previously worked together	43	11.3
	Illegible handwriting	89	23.4
	Lack of patient education	62	16.3
	Lack of family/caregiver education—exclusive nurses	57	15.0
	None of the above apply	64	16.8

). Additionally, 47.8% of the sample believed that the lack of experienced nurses contributed to the occurrence of the error and 24.5% mentioned the lack of support from nursing staff to prevent the occurrence of the error. Lack of supervision by management was cited as a cause of error by 15.8% of the nurses in the sample. Regarding healthcare team communication, 45.3% of nurses reported that the most significant reason for errors was the failure of team communication. 24.5% of the sample cited the lack of nursing care planning as a cause of errors. Additionally, 23.4% of study participants mentioned that the illegible handwriting of the staff also contributed to the occurrence of errors.

Regarding intent or criminal behavior in the error event, 4.2% of the participants reported the presence of intent or criminal behavior. Specifically, 82.4% of the total study population mentioned intentional covering up of the error by management. Additionally, 23.5% reported altering or falsifying documentation in the nursing chart. Theft as an act within the workplace was reported by 17.6% of nurses, fraud by 11.8%, and patient mistreatment in a hospital environment was also reported by 11.8%.

In 62.3% of cases, the event involved a medication error. Specifically, in 19.2% of cases, the medication was given to the wrong patient, and in 18%, an additional dose of medication was administered to the patient. Additionally, an incorrect dosage of medication was reported by 12.7% of participants, administering the wrong medication to the patient was reported by 11% of nurses, and the incorrect administration method of the medication was confirmed by 11% of nurses in the sample. Incorrect drug preparation was confirmed by 10.2% of the study sample, while the wrong route of drug administration was reported by 7.3%. Omission of drug dosage was declared by 6.5%, incorrect use of abbreviations in the medication order was mentioned by 5.3% of participants, and confusing drug labels compared to identical labels of other drugs was reported by 4.9% of nurses. Incorrect prescription was confirmed by 1.2%, and the use of unapproved drugs by the competent authority was mentioned by 0.4% of participants. Some error in recording the drug on the patient’s chart (medical record) was reported by 15.3% of participants, and 73.1% of the nurse sample stated that errors occur in transferring the medical order from the file to the patient’s individual drug chart. In response to an open question about medication recording errors on the patient’s drug chart, nurses also mentioned recording the administered drug before the scheduled administration time, failure to record the administered drug, unclear recording of the administered drug, incorrect recording of the administered drug, recording the administered drug on the wrong patient chart, and recording the dose change instead of the route change. Data on medication error occurrence are provided in

Table 7. Data regarding the existence of a medication error.

		n	%
Did the incident involve Medication error? If yes, what:	Abbreviations in drug writing	13	5.3
	Incorrect drug preparation	25	10.2
	Additional drug dose	44	18.0
	Incorrect labeling for drug administration	12	4.9
	Omission of drug dose administration	16	6.5
	Incorrect prescription	3	1.2
	Unapproved drug	1	0.4
	Incorrect method of administration	27	11.0
	Wrong dose	31	12.7
	Wrong drug	27	11.0
	Wrong patient	47	19.2
	Wrong route of drug administration	18	7.3
	Wrong time for drug administration	9	3.7
	Wrong drug selection	8	3.3
	I don’t know	6	2.4
	Other	4	1.6
Was there any error in recording the drug on the nursing card (chart)?	No	304	84.7
	Yes	55	15.3
If yes, what:	Recording of the administered medication before the scheduled administration time	1	1.9
	Non-recording of the administered medication	9	17.3
	Unclear recording of the administered medication	17	32.7
	Incorrect recording of the administered medication	15	28.8
	Recording of the administered medication in the wrong patient chart	9	17.3
	Recording the dose change instead of the route of administration	1	1.9
Did the error in documentation lead to the reported nursing incident?	No	14	26.9
	Yes	38	73.1

.

Regarding the supervision of clinical nurse managers, the majority of participants (62.4%) reported that supervising nursing care processes is not a factor contributing to nursing errors. Of the total sample, 20.9% mentioned that staff performance was not evaluated over a period of time as a control factor for processes ensuring safe patient care. In response to an open question about nursing supervision, nurses also mentioned the lack of equipment safety supervision, lack of supervision during medication administration (while intravenous medications should be prepared with the presence of two nurses), illegible instructions that were not corrected, lack of proper communication before medication administration, overall lack of supervision by the responsible nurse manager, increased workload with lack of coordination and supervision at the given time, neglect of the responsible nurse in proper checking of the patient’s drug chart, and increased time pressure without supervision.

Regarding clinical factors contributing to nursing errors, 30.3% of the sample reported that nursing care guidelines were not consciously applied by the nurse; 19.2% stated a lack of knowledge on the nurse’s part regarding the application guidelines of nursing care. A percentage of 17.9% of the study participants mentioned inappropriate assignment of nursing tasks and acceptance of responsibility beyond the nurse’s competency level for that specific area of expertise, 15.5% reported insufficient supervision of nursing actions by other staff members with higher administrative responsibility, and 13.7% stated that changes in the patient’s condition and symptoms were not accurately recognized by the nurse, nor were the patient’s reactions to interventions appropriately addressed.

Furthermore, 10.8% of nurses reported that changes in the patient’s condition and symptoms, as well as the patient’s response to interventions, were not properly interpreted by the nurse. Additionally, in response to an open-ended question regarding clinical factors, nurses also mentioned assuming nursing responsibilities without supervision for inexperienced nurses, inadequate information, insufficient familiarization, inadequate admission and supervision of patients in the department, nurse inattentiveness during the application of nursing care, increased workload, nursing staff work pressure, lack of time, failure to identify the patient, application of incorrect practices (culture) in nursing care, overtime, failed interdisciplinary communication, and professional risks. These percentages were reported by nurses as contributing to error occurrence due to the influence of clinical factors during the implementation of nursing procedures.

Additionally, 19.1% of participants believed that preventive measures were not taken for the proper protection of the patient. Additionally, 17.7% of nurses reported that there was no check of certified operational points of the equipment by nurses before its use on the patient and 6.7% reported a violation of preventive measures for the spread of microbes. Furthermore, 26.6% of participants stated that the nursing intervention was not performed with the appropriate level of skill, and 14.0% of the sample recorded that the recommended nursing intervention was not performed at the appropriate time for the patient. Almost 6% of participants reported that the nursing intervention was not performed at all for the patient (

Table 8. Nurses’ perspectives on the factors contributing to the error.

		n	%
Do you believe that Prevention contributed to the nursing error?	Failure to take preventive measures for proper patient protection	71	19.1
	Violation of infection control measures	25	6.7
	No inspection of equipment by nurses before use	66	17.7
	None of the above	214	57.5
	Other	18	4.8
Do you believe that Nursing Intervention (action on the patient) contributed to the occurrence of nursing error?	Nursing intervention was not performed on the patient	22	5.8
	Nursing intervention was not performed when it should have been on the patient	53	14.0
	Nursing intervention was not performed with good skills	101	26.6
	Nursing intervention was performed on the wrong patient	47	12.4
	None of the above	160	42.2
	Other	7	1.8
Do you believe that the Interpretation of medical instructions by those responsible contributed to the occurrence of nursing error?	The predetermined nursing procedure was not followed	55	14.5
	The medical directive was lost	7	1.8
	Nursing intervention was implemented without written medical directive	46	12.1
	Misinterpretation of oral or telephone medical directive by the nurse	48	12.6
	Misinterpretation of the written medical directive	71	18.7
	Misinterpretation of the medical directive, which was not interpreted by the nurse, resulting in incorrect execution	57	15.0
	None of the above	165	43.4
	Other	12	3.2
Do you believe that the nurse’s Professional Responsibility towards the patient contributed to the occurrence of nursing error?	The nurse did not support the safety and clinical stabilization of the patient	51	13.5
	The nurse did not recognize the limits of their knowledge and experience	105	27.9
	The nurse did not refer the patient to additional services as necessary	22	5.8
	No response from the nurse to cover specific requests or concerns of the patient	19	5.0
	Lack of respect for the concerns of the patient/family and dignity	17	4.5
	Patient abandonment by the nurse	10	2.7
	Conflicts/violence from the nurse	8	2.1
	Violation of patient’s comfort by the nurse	3	0.8
	The nurse blames others	40	10.6
	None of the above apply	197	52.3
	Other	7	1.9

).

Furthermore, 18.7% of nurses misinterpreted the written medical directive. Also, 15% of the sample reported that an incorrect medical written directive was given, which was not recognized as incorrect by the nurse according to their level of cognitive and empirical perception, resulting in incorrect execution. The implementation of nursing intervention without a written medical directive was reported by 12.1% of the sample. Additionally, 12.6% of participants reported misinterpretation of oral or telephone medical directives by the nurse and 27.9% mentioned that the nurse performed a nursing action without recognizing the limits of their knowledge and experience. Of the total sample, 13.5% stated that the nurse did not support safety and clinical stabilization during patient care and 10.6% revealed the important meaning of transferring responsibilities from themselves to other colleagues regarding the error incident. In addition, 5.8% of nurses in the sample reported that the nurse did not refer the patient to additional services as necessary, 5% of the sample emphasized the lack of response from the nurse to cover specific requests or concerns of the patient, 4.5% of nurses reported a lack of respect for the concerns of the patient, family, and dignity, 2.7% of nurses reported abandonment of the patient by the nurse, and 2.1% of the sample reported the existence of conflicts and violence between the nurse and the patient. Finally, 0.8% reported violation of the patient’s comfort by the nurse.

According to 46.6% of the participants, the most significant category for nursing error was professional responsibility. Following that were the interpretation of medical guidelines (19.2%), error prevention (16.3%), the influence of clinical factors on error occurrence (9.3%), administrative supervision during the implementation of high-responsibility nursing actions (8.5%), and safe nursing intervention in patient care (8.3%).

In total, 44.4% of the nurse participants reported that the nursing hierarchy did not administratively address the incident, although it was documented as an event. Additionally, 20.8% of the sample stated that there was only a simple recommendation from the administration to the clinic where the nursing error occurred. Another 10.4% mentioned that the management responded to the error by implementing an alternative training program for the nurse involved in the incident. Furthermore, 7.6% of the nurses reported that non-disciplinary action, such as a complaint letter to the nurse who committed the error, was taken, while 2% stated that the responsible nurse was referred for the error to some protective service.

The current study employed a comprehensive framework to classify errors based on outcomes, processes, cognitive reasoning, ethical interpretation, and significance. This approach aims to provide a multifaceted understanding of error factors. However, it is acknowledged that reporting individual performance could add valuable insights into how specific variables influence error classification. Incorporating individual performance data could enhance the analysis by revealing more detailed relationships between personal and contextual factors and the various categories of errors. Future research will consider integrating such data to further enrich the analysis and better understand the interplay between individual performance and error types. This inclusion could offer a deeper exploration of how personal performance metrics interact with error classification, thereby improving the robustness and applicability of the findings.

4. Discussion

This study’s sample comprised 597 nurses with varying demographic backgrounds. Most participants were women aged between twenty-two and thirty-five, and a considerable portion were married with children, aligning with previous studies [5]. This highlights the relatively young age of the nursing workforce in this setting. The sample’s gender distribution is consistent with other research, reaffirming that nursing remains a predominantly female profession despite societal changes [6]. Similarly, in Arakawa et al.’s study [7], the focus was on 6445 nurses to examine factors contributing to nursing errors in hospitals, with an emphasis on younger nurses. This study did not address the male population and lacked detailed demographic information. These demographic traits reflect the typical profile of registered nurses in the healthcare sector, suggesting that the findings are representative of this group. Consequently, the participants’ demographics indicate a diverse nursing staff with a significant proportion of women.

In this study, it was found that male nurses, representing about one-fifth of the sample, experienced workplace errors more frequently than their female counterparts. International research emphasizes the importance of documenting and reporting nursing errors. Notably, in terms of nursing accountability, TERCAP adheres to state laws (The Texas Board of Nursing standards of practice Texas Administrative Code—TAC) concerning the reporting of substandard nursing practices [8].

Consequently, nurses who observe inappropriate nursing practices or behavior from colleagues are expected to report these incidents to ensure safer patient care. Establishing national standards for safe nursing practices and fostering a culture that encourages error reporting, while avoiding bullying and stigmatization, is essential. The initial diagnoses of patients who experienced nursing errors were varied, with malignancies and cardiovascular and respiratory diseases being the most common. The complexity of clinical environments, including human factors such as patient conditions, significantly contributes to errors in the broader context of patient safety. This range of initial diagnoses, predominantly malignancies and cardiovascular and respiratory diseases, is consistent with the findings of previous studies by Al Rowily et al. [9] and Leonard and Frankel [10].

In the present study, more than one-third of the nurses indicated that nursing errors occurred during the morning shift, while the incidence of errors was notably lower during the night shift. This finding aligns with a study conducted in the United States [11], which also reported a higher frequency of errors during morning shifts. However, Mehrabian et al. [12] found that nurses on morning shifts had 4.5 times fewer error incidents compared to those on other shifts. On the other hand, Niu et al. [13] noted that night shift workers in healthcare settings demonstrated reduced alertness and vigilance, leading to a higher probability of errors and near misses. Arakawa et al. [7], who studied 6445 nurses, found that while the risk of errors increased during breaks on night shifts, there was no significant link between shift times and error rates. Additionally, Kahriman and Ozturk observed that night shift nurses had lower attention to patient falls, communication, and monitoring practices, making them more prone to errors compared to their morning shift counterparts [14].

In the survey, one-fifth of the nurses identified the malfunction of communication equipment as a source of nursing errors. However, nearly half of the nurses pointed to failures in team communication as the primary cause of errors. The presence of communication issues and sensory impairments between nurses and patients at the time of an error suggests challenges in delivering accurate care to vulnerable populations [15]. These findings emphasize the critical need for personalized interventions and improved communication strategies when managing patients with diverse needs. Effective communication and collaboration among healthcare team members are crucial for preventing errors and ensuring high-quality patient care [16]. This study highlights the significant role of team dynamics in the occurrence of errors. González-González et al. (2018) conducted a qualitative study on patient safety incidents that revealed communication errors and human factors affecting both healthcare providers and patients. Their findings resonate with the multidimensional approach of this study [17].

Further analysis revealed that issues related to healthcare team members contributed to errors, including ineffective team communication reported by about half of the nurses, inadequate planning by one-fourth of the participants, and illegible handwriting by over one-fifth of the nurses. These results underscore the need for interprofessional education, clear communication protocols, and standardized documentation practices to enhance communication and reduce the risk of errors. The importance of these factors is supported by Leonard et al.’s comprehensive examination of human factors in patient safety, which reinforces the idea that effective teamwork and communication are essential for minimizing errors and improving the quality of care [18].

In addition, environmental factors such as frequent interruptions, multiple emergency situations, and shortages of materials and equipment were identified as significant contributors to errors [19]. These findings, which align with those of the current study, highlight the challenging and fast-paced nature of healthcare environments where nurses are required to manage complex tasks while dealing with frequent disruptions and urgent situations. To tackle these environmental issues, a comprehensive approach is needed, including redesigning workflows, improving resource allocation, and implementing strategies to minimize distractions. This study also explored whether there were any disciplinary actions taken against nurses prior to the occurrence of errors. About one-fourth of the nurses reported having been previously reprimanded by management concerning the correct execution of nursing procedures. In a similar study involving 725 nurses that utilized the same research tool (TERCAP) as the current study, over half of the participants had experienced disciplinary actions, with one-third ultimately leaving their positions due to termination [20].

In the current study, significant percentages were found regarding the frequency of errors and the educational and professional background of nurses. It is possible that nurses with higher educational qualifications have a higher level of awareness in sharing errors that were recorded under their responsibility. This unexpected finding contradicts common ideas about the link between education and error rates and therefore requires additional research for possible explanatory factors. However, in a study by Swart et al., similar to the present study, the researchers reported that registered nurses, as opposed to enrolled nurses, more frequently documented nursing errors such as medication errors, bed sores, and infections because they may have had a better understanding of their role in reporting errors [21]. Similar findings to the present study were also reached by Almutary and Lewis, who reported in their research that nurses with higher educational levels more frequently documented errors in their workplace [22].

The present study also explored the relationship between job stability and error rates among nurses, revealing some noteworthy patterns. It was observed that nurses holding permanent positions in the hospital reported a higher frequency of errors compared to those employed under fixed-term contracts. This unexpected finding suggests that permanent roles might come with additional pressures or responsibilities that could increase the likelihood of errors. It raises questions about whether the stability and expectations associated with permanent positions contribute to heightened stress or anxiety, which in turn might lead to a higher incidence of mistakes. This observation aligns with similar findings reported by Evans et al. in 2006. Their study found that nurses in permanent roles were more prone to report errors, likely due to their familiarity with the error reporting process and the protocols involved. This familiarity might make them more comfortable with disclosing mistakes, as they are well versed in managing and responding to such incidents, unlike their colleagues on temporary contracts who might not be as experienced or aware of the procedures [23].

In addition to examining job stability, this study also analyzed how years of experience among nurses correlated with error rates. Contrary to the common assumption that greater experience leads to fewer errors, the findings revealed that more experienced nurses reported a higher number of errors. This trend suggests that experience alone might not necessarily reduce error rates. Instead, it prompts a reconsideration of the belief that experience inherently improves error prevention. Ajri-Khameslou et al., conducted a study using personal interviews with nurses and found that less-experienced nurses were more likely to report errors. In contrast, more-experienced nurses might prefer to address or cover up errors based on their deeper understanding of the nuances of their work and their accumulated knowledge over the years [24]. This suggests that experienced nurses might have developed strategies to manage or obscure errors rather than reporting them openly.

Furthermore, the research by Sozani et al., provides additional context by showing that, in their study, nursing errors, particularly medication errors, did not demonstrate significant statistical differences related to variables such as gender, age, or professional experience. This suggests that, while certain factors may influence error rates, other underlying issues or systemic factors might play a more substantial role in error occurrences [25]. Overall, these findings highlight the complexity of error reporting in nursing and suggest that factors such as job stability and experience may influence error rates in ways that challenge traditional assumptions. Addressing these issues may require more nuanced strategies and interventions to better understand and mitigate the factors contributing to nursing errors.

Delving into the hierarchical structure of nursing positions revealed an interesting trend. Nurses occupying higher positions in the administrative hierarchy were disproportionately represented among those reporting errors, challenging the conventional belief that higher nursing positions are associated with lower error rates. Conversely, nurses without a defined position within the nursing hierarchy reported encountering errors less frequently, implying a potential focus area for error prevention strategies. Various researchers [23,26] similarly supported that nurse in higher levels of the administrative hierarchy (nursing managers, senior nurses) exhibited greater willingness and frequency in documenting the presence of nursing errors.

Research into the emotional repercussions of nursing errors has shown a notable connection between the occurrence of these errors and the experience of negative emotions among nurses. Nurses who have faced errors in their workplace reported experiencing more frequent and intense negative emotions compared to their peers who had not encountered such issues. This emotional burden highlights the psychological strain associated with professional errors and emphasizes the need for robust support systems to help nurses manage the aftermath of these incidents. In line with these findings, Mahat et al. [27] discovered that medication errors, regardless of the level of harm inflicted on patients, had a detrimental emotional effect on the healthcare staff involved. The stigma linked to errors and their reporting often persists, leading healthcare professionals to question their own competence. Scott and colleagues further reported that nurses dealing with errors experienced a range of negative emotions, including despair, job dissatisfaction, grief, self-doubt, mourning, and difficulty concentrating, in the aftermath of such events [28].

5. Conclusions

This study’s extensive analysis of nursing errors offers a detailed understanding of the diverse factors that contribute to their occurrence. By classifying errors according to outcomes, processes, cognitive reasoning, ethical interpretation, and significance, this study provides a comprehensive framework for examining errors from multiple angles. This analysis highlights the complexity of the challenges faced in nursing practice. It underscores the importance of integrating systemic, clinical, and individual factors into intervention strategies. These strategies include developing protocols for medication administration, providing ongoing training, establishing clear communication channels, offering administrative support, and fostering an open culture of communication and learning.