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Errors of Omission in Nursing Care and Its Impact on Patent Care.

Think of a time when you began your shift and things started of smoothly. You had a manageable patent assignment, there was enough staff and the electronic medical record was up and running. As the day progressed, you discharged one or two patents, admitted two new patents, the unit lost a patent care assistant, and you still have one complex patent. This patent is NPO after bowel surgery, has orders to ambulate three times a day, sit in a chair twice a day, is receiving antibiotics, total parenteral nutrition (TPN) and lipids, as well as pain medications as needed every six hours. The end of this shift is nearing and you realize that your patent ambulated once during your shift. You were so busy with discharging and readmitting patents, as well as passing medications, that you forgot to ensure the patent sat in a chair during your shift. You suddenly become overwhelmed with what is priority. You still have antibiotics to hang, TPN and lipids to check of and hang, along with reviewing all orders before the oncoming shift arrives in 30 minutes. It becomes a quick decision of what appears to be priority. You hang the medications because they cannot be late, make sure all clinical data are entered in the computer, and start checking of all orders from the day. Your relief arrives and you report of. The oncoming nurse asks, "Did the patent get out of bed and into a chair today? There is hesitation in your answer as the events of the day are still overwhelming you. You are informed by the oncoming nurse that the patent did not get out of bed yesterday to sit in a chair either.

How did you feel when you reported of? How did you feel leaving your shift? Guilt, shame, the thought "I will stay and help complete the task" or "I can't work like this one more day" or maybe even "No mater what I try to do, it's not good enough"? Likely all nurses have been there at some point. The following article will discuss how patents and nurses can be affected by errors of omission, the implications, and strategies to prevent these errors.


The Institute of Medicine (IOM), now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine issued a report, To Err is Human (2000), that initated the patent safety movement. Since that time, most of the efforts in improving patent safety have focused on errors of commission; however, many researchers believe that errors of omission can occur even more frequently than errors of commission (Kalisch, 2015).

Errors of commission are commonly thought of as doing the wrong thing, e.g., administering a wrong medication or surgery on the wrong body part. Kalisch (2015) defined errors of omission as "any aspect of required patent care that is omitted or delayed" (p.7). Examples of errors of omission include, but are not limited to, failing to carry out ordered interventions, such as administering medications, repositioning a patent to prevent skin breakdown, or ambulating a patent to help mobility. Nursing errors of omission, also known as missed nursing care, can have a significant impact on patents, their family members, and on nurses themselves.

Errors of omission are often not discussed during shift change or patent hand of, which may have a disastrous effect on patent care and patent safety. This article will explore the current literature and regulatory requirements to provide a framework for nursing care that minimizes errors of omission.


In 2001, the IOM continued the exploration of patent safety issues by publishing a series titled Crossing the Quality Chasm. This series cited the direct impact that the nursing work environment has on patent outcomes. As a result, the IOM recommended transforming the nursing work environment to include bedside shift report and quiet zones for the preparation of medications. While the 2001 IOM report cited the impact of the nursing work environment on the potential for errors in care, the discussion was lacking in the nursing-specific environmental factors that directly influence nursing decision-making and the resultant provision of nursing care. Nursing-specific environmental factors directly affect nurses, and may lead to nurses making decisions that abbreviate, delay, or omit care due to an overwhelming task/work load (Kalisch, Landstrom, & Hinshaw, 2009).

Kalisch coined the term "missed nursing care" in 2006, and she launched multiple studies beginning in 2009 aimed to better understand errors of omission. The inital research indicated that the issue of missed nursing care was far-reaching and prevalent (Kalisch, 2015). The influence of these errors on nursing care had not previously been studied prior to Kalisch's work. Kalisch refocused research on errors of omission, to focus specifically on missed nursing care or errors of omission specific to nursing. Using Kalisch's survey instrument known as the MISSCARE Survey, focused studies revealed that staffing levels, type of staffing, and teamwork predicted missed nursing care. In turn, missed nursing care predicted job and occupation satisfaction, intent to leave, turnover, and patent outcomes (Kalisch, 2015).

When frst looking at missed nursing care in 2006, Kalisch identfied nine areas of commonly missed nursing care and seven themes relating to why nursing care was missed. The reasons for missed nursing care ranged from poor or low staffing, inadequate use of existing staffing resources, poor teamwork, time needed to complete nursing interventions, habit, personal denial, and ineffective delegation (Kalisch, 2006). With these findings, nursing-specific maters were brought to light. Additionally, the realization was made that more information was needed to define missed nursing care, along with a better understanding of what leads to omission of nursing care.

Top Five Areas of Missed Nursing Care

In several studies across numerous healthcare systems, Kalisch (2015) found that the top five areas of missed nursing care consistentily included:

* Ambulation

* Interdisciplinary care conference attendance

* Oral care

* Timely medication administration

* Turning patents every two hours

In an era of limited resources, nurses must prioritze nursing care. Omitting any of the above, just once may not seem significant; however, the effects can have an impact on patents. Research has demonstrated that failing to ambulate patents has been linked to a decline in walking ability within 48 hours of hospitalization (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990). More recently, Kalisch (2015) noted that several studies found failure to ambulate a patent was associated with neurologic impairment, pneumonia, impaired skin integrity, prolonged hospitalization, alteration in comfort, and an overall decrease in physical mobility.

Using patent surveys, Kalisch (2015) found that the most important issues for patents included oral care, ambulation, getting out of bed into a chair, being updated regularly on tests/procedures, and bathing. Although these are all elements of basic nursing care and are priorities for patents, they may often be overlooked and become errors of omission for nurses.

Top Reasons for Missed Nursing Care

Kalisch (2015) conducted several studies to understand why errors of omission occur. Study findings were consistent, in that reasons for missed nursing care across multiple organizations included staffing, material resources, communication/teamwork, interruptions, multi-tasking, task switches, and fatigue. Although it is beyond the scope of this article, Kalisch (2015) discussed each study thoroughly in Errors of Omission, How Missed Nursing Care Imperils Patents.

The Standards of Nursing Practice and the Impact of Missed Nursing Care on Nurses

Errors of omission can influence whether a nurse is meeting the minimum standard of care and competency requirements to provide safe and effective care to patents. Errors of omission diminish the ability of the nurse to provide a safe environment and some errors may even lead to disciplinary action. Texas Board of Nursing Rule 217.11(1)(B) states that each nurse must implement measures to promote a safe environment for all patents and others (Texas Board of Nursing, 2017). The impact of these errors on nurses may include moral distress, decreased job satisfaction, compassion fatigue, and burnout (Kalisch, 2015).

Moral Distress

Not only are patents impacted by errors of omission, but the impacts on nurses themselves are numerous. Nurses may bear a significant amount of guilt as well as face ethical dilemmas when they are not able to provide all of the care patents need. Kalisch (2015) suggests that dissatisfaction with job and occupation, intent to leave, turnover, moral distress, compassion fatgue, and burnout are all results of missed nursing care.

Moral distress is defined as "when one knows the right thing to do, but insttutional constraints make it nearly impossible to pursue the right course of action" (Jametion, 1984, p.6). When nurses are unable to provide the nursing care they believe patents require due to the work environment, they may experience moral distress and subsequently leave their current employment position.

Employment Satisfaction and Turnover

Very few studies link job satisfaction with quality of patent care. Nurses have reported satisfaction with providing quality care to patents and feeling they are making a difference (Kalisch, 2015). The Triple Aim centers around improving the individual experience of care, improving the health of populations, and reducing the per capita cost of healthcare (Berwick, Nolan, & Whitingtion, 2008). Sikka, Morath, and Leape (2015) suggested that there should be a fourth aim, which is improving the experience of providing care, creating an engaged and productive workforce.

There are only a few studies that link the impact of the quality of nursing care provided at the bedside to subsequent nurse turnover. One such study by Larrabee et al. (2003) found that when registered nurses were satsfied in their setting, they were 2.4 times less likely to leave than other registered nurses.

Using the MISSCARE Survey instrument in 11 hospitals, Kalisch (2015) found that there was a direct correlation of missed nursing care with job satisfaction and the intent to leave. Based on Kalisch's findings, those nurses who reported greater fulfillment with their current job, profession, and teamwork were less likely to be found contemplating changing jobs.

Compassion Fatgue and Burnout

Other impacts on missed nursing care include burnout and compassion fatgue which influence quality of nursing care and nurse satisfaction. Turnover can be costly, with estmates ranging from approximately $20,000 to $60,000 per nurse (Robert Wood Johnson Foundation, 2009). Missed nursing care can predict nursing staff satisfaction and intent to leave leading to costly turnover. With a looming shortage and increased demand for nurses, efforts should be aimed at retaining nursing staff by reducing missed care opportunites.

Strategies to Decrease Frequency of Missed Nursing Care

Kalisch (2015) developed four overarching strategies to decrease the frequency of missed nursing care. These strategies included culture and leadership, teamwork, patent and family engagement, and technology. See Table 1 for examples of each strategy.

Organizational culture and leadership are essental to a patent safety culture. Leape (2009) suggested that a culture of safety is based upon:

* Acknowledgment that errors are primarily caused by system failures

* Elimination of punitive environments

* Transparency over secrecy

* Patent-centered over provider-centered

* Team based collaborative work models of care

* Accountability is universal and reciprocal, not top-down

Just as these strategies are appropriate to prevent errors of commission, they are also appropriate to protect against errors of omission.


Kalisch (2015) suggested several strategies to enhance teamwork in nursing which can ultmately enhance the quality of nursing care. These strategies include redesigning patent units, team training, and making changes in the model of nursing care delivery. During patent hand offs, effective communication is essental. Kalisch (2015) suggested several methods for improving communication, such as face-to-face verbal reports and the use of mnemonics to include SBAR (Situation, Background, Assessment, Recommendation) or I PASS the BATION (introduction, patent, assessment, situation, safety concerns, background, actions, timing, ownership, next).

Patent and Family Engagement

Although largely ignored in the past, involving patents and their families in patent care is a critical element of improving patent safety. Historically, patents have been passive recipients of care. By nurses improving patent engagement, education, and safety, patents are now more involved in their care. Nurses are always patent advocates and, as such, must involve patents in their care. Kalisch (2015) suggested that nurses advocate for patent involvement by promoting liberal visitation, conducting interdisciplinary rounds at the patent's bedside, including family members in rounds, and providing patents with access to and the ability to write on their own healthcare record. Other methods to consider are performing change-of-shift report at the patent's bedside, putting patent advocates on the care team, developing training programs and tools, creating patent councils, and involving patents and families in healthcare organization commitees.


There is little research that demonstrates how the use of technology can reduce the incidence of missed nursing care; however, many of the technologies currently in use include alarms, alerts, or reminders to the nurse that care needs to be completed (Chen et al., 2013; Hatler, Hebden, Kaler, & Zack, 2010; Huang et al., 2004). Studies have suggested that the use of electronic reminders reduced missed nursing care (Piscoty & Kalisch, 2014; Piscoty, Kalisch, & Gracey-Thomas, 2015). Other studies have suggested that there is a positive impact with the use of health information technology.

Future Research

Although it has been suggested that errors of omission outnumber errors of commission, errors of omission are not yet studied as extensively as errors of commission. However, studies are beginning to emerge. In November 2017, Poghosyan et al. published a study looking at errors of omission in primary care with similar findings to Kalisch's work. In this study, Poghosyan et al. found that omitting patent teaching, patent follow-up, emotional support, and mental health needs were the predominant topics of missed care in the primary care setting.


The implications of the errors of omission for nurses are numerous. Research has shown that nurses want to provide quality nursing care, but organizational restraints may sometimes hinder these efforts. Addressing errors of omission improves patent safety while upholding minimum standards of nursing care. As patent advocates, nurses can prioritze patent needs and coordinate with appropriate members of the healthcare team when those needs are not being met. It takes a village of team providers to ensure patent safety. Nursing is consistently ranked as the most trusted profession. Patents trust nurses to do the right thing and prevent errors, including errors of omission.


Berwick, D., Nolan, T., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Afairs, 27(3), 759-769. doi:10.1377/hlthaf.27.3.759

Chen, Y., Chi, M., Chen, Y. , Chan, Y., Chou, S., & Wang, F. (2013). Using a criteria-based reminder to reduce use of indwelling urinary catheters and decrease urinary tract infections. American Journal of Critical Care, 22(2), 105-114.

Hatler, C., Hebden, J., Kaler, W., & Zack, J. (2010). Walk the walk to reduce catheter-related bloodstream infections: Using evidenced-based practices, nurses can help prevent deadly infections linked to central venous catheters. American Nurse Today, 5(1), 26-30.

Hirsch, C. H., Sommers, L., Olsen, A., Mullen, L., & Winograd, C. H. (1990). The natural history of functional morbidity in hospitalized older patents. Journal of the American Geriatrics Society, 38(12), 1296-1303.

Huang, W., Wann, S., Lin, S., Kunin, C., Kung, M., Lin, C., & Lin, T. (2004). Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infection Control and Hospital Epidemiology, 25(11), 974-978.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, D.C: The National Academies Press. doi: 10.17226/9728

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press. doi: 10.17226/10027

Jametion, A. (1984). Nursing practice: The ethical issues. Englewood Clifs, NJ: Prentce-Hall.

Kalisch, B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

Kalisch, B. (2015). Errors of omission: How missed nursing care imperils patents. Silver Spring, MD: American Nurses Association.

Kalisch, B., Landstrom, G., & Hinshaw, A. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517.

Larrabee, J. H., Janney, M.A., Ostrow, C.L., Withrow, M. L., Hobbs, G.R., & Burant, C. (2003). Predicting registered nurse job satisfaction and intent to leave. Journal of Nursing Administration, 33(5), 271-283.

Leape, L. L. (2009). Errors in medicine. Clinica Chimica Acta, 404(1), 2-5.

Piscoty, R., & Kalisch, B. (2014). The relationship between electronic nursing care reminders and missed nursing care. Computers, Informatics, Nursing, 32(10), 475-481.

Piscoty, R., Kalisch, B., & Gracey-Thomas, A. (2015). Impact of healthcare information technology on nursing practice. Journal of Nursing Scholarship, 47(4), 287-293.

Poghosyan L., Norful A. A., Fleck, E., Bruzzese J.-M., Talsma, A., & Nannini, A. (2017). Primary care providers' perspectives on errors of omission. Journal of the American Board of Family Medicine, 30, 733-742.

Robert Wood Johnson Foundation (2009, July 29). The business case/cost of nurse turnover. Retrieved from htp://

Sikka, R., Morath, J., & Leape, L., (2015). The Quadruple Aim: Care, health, cost and meaning at work. Retrieved from htp://

Texas Board of Nursing. (2017). Rules and regulations relating to nurse education, licensure & practice. Retrieved from htp://

by Linda Laws, BSN, MSN, RN and Calyn Hughes, MSN, RN, CPNP
Table 1 - Strategies to Decrease Frequency of Missed Nursing Care

Strategy                    Example

Organizatonal Culture       Acknowledgment that system failures can
                            contribute to errors; eliminaton of punitive
& Leadership                environments; team based collaboratve work
                            models of care; accountability
Teamwork                    Team training; model of nursing care
                            delivery; redesign patent care units
Patent & Family Engagement  Liberal visitaton; interdisciplinary rounds
                            at patent bedside; bedside change of
                            shif report
Technology                  Electronic reminders; checklists
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Author:Laws, Linda; Hughes, Calyn
Publication:Texas Board of Nursing Bulletin
Date:Apr 1, 2018
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