Missed Care - Preventing Errors of Omission Conference
- : Melbourne VIC 3000
Have you ever gone home from work knowing that you haven’t completed an aspect of nursing care, perhaps due to inadequate time or resources? Have you come across situations where care has not been given at all? Do you find yourself routinely having to complete non-nursing duties, such as answering phones or obtaining supplies? How can this be prevented? Attend this conference and find out:
- What care is most likely to be missed?
- What triggers “errors of omission” and “missed nursing care”?
- How does “missed care” undermine quality?
- Are there common predictors?
- How to prevent missed care when time is not on your side
- The consequences of multitasking and much, much more …
Don’t miss the opportunity to engage in this highly interactive event – book now!
Schedule Day One
8:30AM REGISTRATION FOR DAY ONE
Healthcare Complaints and Missed Care
The role of the health complaints commissioner is to resolve complaints made by the public in support of safe and ethical health care. This session looks at the framework for complaints and the type of complaints that reflect missed care by all health professionals.It includes:
- What is the Health Complaints Act?
- How does missed nursing care relate to healthcare complaints?
Dr Linda Starr
How Missed Nursing Care is Defined – Error of Omission or Error of Commission?
An error of omission occurs when specified care is not provided. This differs to an error of commission where the wrong practice is carried out. In this introductory session, we will look at why both are detrimental practices and how knowing their difference is important. It includes:
- What is missed nursing care believed to be?
- Is patient refusal missed care?
- What are the consequences?
- What kind of vigilance is needed by nurse managers?
10:30 MORNING TEA
What Type of Care is Commonly Missed?
Do you know which nursing care is most likely to be missed on a shift and why? This session looks at evidence that reveals the most common types of missed nursing care. It includes:
- The most common errors of omission
- Examples of consequences of missed care
Dr Linda Starr and Fran Pearce
Audience Participation – What are Your Experiences of Missed Care?
In this open forum, we encourage participants to discuss their observations and problem-solving tactics to missed care situations. It will also include:
- When should missed nursing care become a reportable incident?
12:45PM LUNCH AND NETWORKING
Missed Care – By Design!
When nurses are located in close proximity to their patients, it is easier to keep an eye on them. It also means excessive walking is diminished and time taken to respond to call bells is improved – basically, human performance is optimised. This session looks at how the configuration of a workplace can actually encourage missed care and what can be done to prevent it. It includes:
- Examples of how the physical environment can create a situation where missed care can thrive
- What this means for teamwork, education opportunities, and supervision of novice nurses
Quality, Risk, and Missed Nursing Care
It is well-known that care between units within health can differ widely, but the reason for this is not always clear. Typically, when things go wrong, quality care gaps will focus on errors of commission. This session looks at what is emerging as the elephant in the room – errors of omission. It includes:
- How can nurse managers focus their staff on errors of omission and how it relates to quality care?
3:15 AFTERNOON TEA
Deteriorating Patients and the Environment of Care
It should now be clear that many reasons compound to create suboptimal work conditions that can lead to missed nursing care. When this involves patient deterioration, the consequences can be dire. So why does this happen? In this session, we will consider the contribution that the broader environment of care has in creating an incubator for such situations to occur. It will include a case study. Join in this debate that looks at the impact of the environment of care in which nurses work and consider what can be done to fix the problem.
4:15 CLOSE OF DAY ONE OF CONFERENCE
9:00AM COMMENCEMENT OF DAY TWO
Dr Linda Starr
Legal Ramifications of Missed Nursing Care
In this session, we will analyse several court cases that involve errors of omission. This will include reference to:
- The Code of Conduct
- Standards of Care
It’s Not my Job … Breaking the Cultural Norm
Peer pressure is very strong – so strong that sometimes even the most assertive independent thinkers may comply with the will of the group. Staff may simply omit care because of cultural norms that exist in a particular workplace. This session looks at how a nurse manager can be influential in interpreting cultures of complacency and in turning a culture around. It includes:
- Start at the beginning – the power of orientation
- Creating a workplace that values independent thought
- The consequences of leaving work to the next shift
10:45 MORNING TEA
Interprofessional Communication, Patients, and Missed Care
Increasingly, patient care relies on interprofessional interventions. Interprofessional communication, including genuine patient understanding, is critical to the provision of holistic care. This adds significant complexity to the work of nurses. This session will consider, in brief, two aspects of care: interprofessional and patient communication. It includes two case scenarios and asks the questions:
- What went wrong with the communication?
- What were the challenges?
- What is the impact of “status asymmetry” on communication?
Kathryn Salamone and Dr Linda Starr
Audience Participation – Examples of Good Interprofessional and Patient Communication and Why They Worked
12:30PM LUNCH AND NETWORKING
Decision Regret and the Welfare of Nurses
What is the long-term impact on nurses living with knowing that the necessary care required from them on their shift was not provided? This session looks at the relationship between the welfare of nurses and the realisation that nursing care was omitted. In particular, it will examine the issue of decision regret and nurse burnout. It includes:
- What do we know about causes of burnout and do they include errors of omission?
- What can nurses in management positions do to avert such situations?
Mark Aitken and Dr Linda Starr
Audience Discussion – Mark Aitken and Dr Linda Starr
In this session, the audience will be invited to discuss the challenges faced by nurse management when staff are not able to provide necessary care due to reasons outside their control. It will particularly address the prevention and management of nurses experiencing moral distress.
2:45 AFTERNOON TEA
Interruptions and Task Switching – Causes of Missed Care?
If a task that a nurse is performing is interrupted, does it take longer or less time to complete the task? The answer may surprise you. Literature has discovered that it takes less time, which might suggest some care is missed to compensate for the lost time. This vibrant session will look at brain function, multitasking, interruptions, and how this impacts your day-to-day activities. Find out:
- Are we actually able to multitask?
- Does multitasking lead to greater interruptions?
- How long does it take to resume an activity once interrupted?
- Does the time on task affect the outcome?
- What happens to your work safety when you have too many distractions?
4:00 CLOSE OF CONFERENCE AND EVALUATIONS
The Goal Need for Program
“Missed nursing care” has been reported as a common phenomenon, but one that has been paid little attention. It is a subset of “errors of omission” of care that can occur in any health setting, It results from when any of the aspects of standard required nursing care is not provided. Many reasons have been identified for missed nursing care and they are similar across settings. There is a need to understand the concept of “missed nursing care”, common causes, and procedures and care that are most likely to be missed, as well as how these problems can be avoided. A timely conference that uncovers this issue is essential to ensuring safe patient care will be provided and to offer an opportunity for satisfaction to increase.
Purpose of Program
The purpose of this conference is to explore the problem of missed nursing care, discover its breadth and causes, and identify practical strategies for minimising the potential for errors of omission.
Your learning outcomes:
Use insights from research about predictors of missed nursing care to identify areas of concern in your own workplace setting
Review workplace practices to ensure prioritisation and effective delegation of workload and accountability are clearly communicated
Participate in a decision-making forum to promote practical strategies that minimise the potential for missed nursing care in your setting
Reflect on personal strengths that you can use to assist your nursing team to collaborate on strategies to reduce the incidence of missed nursing care
Dr Linda Starr is a general and mental health qualified nurse, lawyer, and associate professor in the School of Nursing ... Read More
Karen Cusack was appointed Victoria’s inaugural health complaints commissioner in February 2017, to oversee the introduction of the Health Complaints ... Read More
Fran Pearce is an education coordinator at a large metropolitan teaching hospital. She has extensive experience in orthopaedic nursing, including ... Read More
Amanda Charles is the associate director: risk at Austin Health, where she has been for the last five years. Amanda ... Read More
Alexandra Gillian has been a Registered Nurse for 29 years and an emergency ambulance paramedic for 13 years, with intensive ... Read More
Kathryn Salamone has worked in nursing for over 30 years. In the years since, Kathryn has completed a Masters of ... Read More
Mark Aitken has been a proud Registered Nurse for over 30 years. He has worked in many areas of nursing ... Read More
To Be Determined