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Nurse numbers play a key role in preventable deaths.
That’s one of the key findings of PhD research by Charles Darwin University’s Dr Melanie Underwood, who used coronial reports to analyse nurse-related adverse events resulting in the death of patients.
Underwood leveraged a system originally used by the US military to analyse failures resulting in adverse events called the Human Factors Analysis and Classification System, and used 99 variables such as nursing shift, type of death, specific types of unsafe acts and environmental factors.
“I found that almost all variables that had led to the deaths in each case were foreseeable and therefore often preventable,” Underwood said. “In the majority of cases, the number or skill mix of nurses was related to the unsafe act occurring.”
She said while the information surrounding staffing numbers is not new, particularly in remote and regional areas, the research reinforces it as a major issue contributing to preventable deaths.
“The research has confirmed that unsafe acts are not single, isolated events but the result of an error trajectory with influencing factors at all levels of an organisation,” she said. “The factors contributing to error can be identified and mitigated which can then prevent deaths from occurring.”
Underwood said that following a hospital review at the time of a death there is often no follow up with staff at the frontline of care to analyse the gaps in the system leading to the failure, and how and why it happened.
“As nurses represent the largest group in the healthcare workforce, providing 24-hour care, they are in a key position to contribute to improving patient safety.”
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