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Nursing Research and Practice
Volume 2016, Article ID 8416158, 7 pages
Research Article

Real-Time Reporting of Small Operational Failures in Nursing Care

1School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
2Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

Received 26 July 2016; Accepted 19 October 2016

Academic Editor: Marja L. Kukkurainen

Copyright © 2016 Kathleen R. Stevens and Robert L. Ferrer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Addressing microsystem problems from the frontline holds promise for quality enhancement. Frontline providers are urged to apply quality improvement; yet no systematic approach to problem detection has been tested. This study investigated a self-report approach to detecting operational failures encountered during patient care. Methods. Data were collected from 5 medical-surgical units over 4 weeks. Unit staff documented operational failures on a small distinctive Pocket Card. Frequency distributions for the operational failures in each category were calculated for each hospital overall and disaggregated by shift. Rate of operational failures on each unit was also calculated. Results. A total of 160 nurses participated in this study reporting a total of 2,391 operational failures over 429 shifts. Mean number of problems per shift varied from 4.0 to 8.5 problems with equipment/supply problems being the most commonly reported category. Conclusions. Operational failures are common on medical-surgical clinical units. It is feasible for unit staff to record these failures in real time. Many types of failures were recognized by frontline staff. This study provides preliminary evidence that the Pocket Card is a feasible approach to detecting operational failures in real time. Continued research on methodologies to investigate the impact of operational failures is warranted.