Background

Patient safety is defined by the Canadian Patient Safety Institute (CPSI) as "the pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes".1^(p.43) It is important to note that not all adverse events are due to errors. The terms "preventable adverse events" are often referred to as "patient safety incidents", "avoidable events" or "errors" and are inconsistently used within the literature. Preventable adverse events are those that result in harm to patients and are not related to the patient's medical condition.1 Near misses are potentially harmful events that do not reach the patient for one reason or another.1

The Institute of Medicine's landmark report released in 2000 revealed that nearly 100,000 people die every year in the United States (US) alone due to medical errors and that 36.9% of these are preventable.2 This report was the first of its kind and sparked the patient safety reform. These types of events are not isolated to the US, and the number of adverse events could be as much as 10 times higher than previously understood.3 In the Netherlands, researchers conducted a longitudinal study and found that in 2004, 4.1% of individuals receiving health care experienced an adverse event, and this increased in 2008 by 2.1%.4 In Dutch hospitals, human errors have been found to be the greatest contributor to adverse events, and 61% of those errors are likely to have been preventable.5 Additional research conducted in Australian, Swedish and Portuguese hospitals indicates reported adverse event rates as being between 3% and 16% with 30-70% of these events deemed preventable.6-13

The abundance of patient safety events is also well documented within the Canadian healthcare system. In 2004, researchers in Canada reviewed acute care facility charts and found that 7.5% of patients experienced a patient safety event, and that more than 50% of them were preventable.14 Likewise, a retrospective cohort study of home care patients in three Canadian provinces (Manitoba, Quebec and Nova Scotia) between 2009 and 2012 revealed that 10% of these patients experienced a patient safety event and 60% were preventable.15 The largest number of events reported were related to falls, wound infections and mental-health-related issues. In 2013, researchers conducted the Pan-Canadian Home Care Study and following secondary health database reviews and chart audits found that 13% of patients experienced a patient safety event.16 Events most frequently reported were related to injurious falls, other injuries and medication administration.

The global concern for patient safety led to the development of government and private patient safety boards including the Australian Council for Safety and Quality in Healthcare (ACSQHC),17 the World Alliance for Patient Safety18 and the CPSI.1 In 2005, the ACSQHC created a framework for investigating patient safety events that transcends healthcare disciplines.17 The World Alliance for Patient Safety and the World Health Organization (WHO) developed a classification system that offers a framework for exploring patient safety regardless of where the event occurs. The knowledge gained using this framework could also be transferred across disciplines and settings.18 The CPSI created the Canadian Patient Safety Framework based on the CanMEDS framework that was designed to facilitate integration of patient safety concepts within education.1

The high rates of reported patient safety events have instigated the move toward healthcare improvement initiatives worldwide. For changes to be made, details of the events need to be communicated in a formal and transparent manner. Formally, reporting is the process of documenting the details of an event.1 Reporting of all errors by all healthcare professionals is essential to improve the quality of care that patients receive. Researchers have studied nurses' error reporting rates and found that only between 3% and 37% of their errors are reported.19-22 In 2012, Unver et al.21 compared the reporting rates of practicing nurses and nursing students and found that nursing students report errors at greater rates than practicing nurses (45% and 37%, respectively). Within the literature, causes of errors and under-reporting are often conflated.

There are many factors that influence the reporting of patient safety incidents. Fear is known to be a major influence hindering nurses' inclination to report errors, and this includes fear of consequences, judgment, rejection and blame.22,23 An environment with supportive leadership reduces fears and encourages the reporting of errors.24 Uncertainty about what represents a reportable error may also deter the reporting of errors by nurses.20,25-27

The factors contributing most frequently to errors made and reported by practicing nurses include illegible physician handwriting, exhaustion and fatigue, distraction and communication.28-30 Errors made by novice nurses are attributed to their limited detection and intervention skills,31-32 hence_, being a new graduate has also been also stated as a contributing factor to making errors.33 Researchers have explored the staffing mix and reported that when there is an increase in registered nurses on a unit the error rates decrease.34 This was supported by Chang and Mark35 who also found a decrease in severe error rates when the nurses on the unit were Baccalaureate prepared.

An investigation of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, Epistemonikos and PROSPERO indicated that there are no existing scoping reviews or systematic reviews on this topic. Nursing is one of the healthcare professions that has always stressed the importance of quality care.36 Nursing regulatory bodies have developed competencies that ensure that nurses are practicing safely and competently.36,37 Since the nursing students of today are the practicing experts of tomorrow, the purpose of this review is to explore the occurrence of nursing student errors as reflected within the literature. A scoping review has been selected as the methodology of choice for this review because this is an emerging area of research and our aim is to explore, tally and map the various types of errors that have been reported by nursing students. A scoping review will facilitate this activity and provide the structure to examine the concept of student nurse errors.

Inclusion criteria

Types of participants

Nursing students who are enrolled in either registered nursing (RN) programs or registered/licensed practical nursing programs (RPN/LPN), in any year of their nursing program, actively participating in a clinical placement will be considered in this review.

Concept

The current review will focus on the concept of patient safety errors including hazards, adverse events, healthcare-associated harm, patient safety incidents, reportable circumstances, near misses, harmful incidents, no harm incidents and injuries to patients. Injuries to healthcare providers (e.g. needle stick injuries) will be excluded.

Context

The context will be health care provided by nursing students in any setting, including acute/critical care, complex continuing care, long-term care or community settings.

Types of studies

The scoping review will include both quantitative and qualitative evidence. The quantitative studies will include both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. Descriptive epidemiological study designs including case series, individual case reports and descriptive cross-sectional studies will also be considered for inclusion.

The qualitative studies will include, but not be limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

In the absence of research studies, other text such as expert opinion papers, discussion papers, position papers and reports will be considered.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published from the year 2000 to 2016 will be considered for inclusion in this review. The start date of 2000 has been selected because this was when the WHO released the first report raising awareness of the issue of patient safety.2 This review will only include studies published in English. To provide the broader picture of all available literature on this topic, the non-English literature will be tallied (but not translated).

The databases to be searched will include:

MEDLINE

CINAHL

Embase

PsycINFO

Scopus

Web of Science.

The search for unpublished studies will include:

Dissertation Abstracts, ProQuest - Nursing and Allied Health Source Dissertations and Google Scholar.

Initial keywords to be used will be:

nursing students, patient safety, errors, hazards and near misses.

Data extraction: charting the results

A draft charting table or form will be developed to record the key information of the source, such as author, reference and results or findings relevant to the review question (Appendix I). This may be further refined at the review stage and the charting table updated accordingly. Some key information that will be extracted includes

* Author(s)

* Year of publication

* Origin/country of origin (where the study was published or conducted)

* Aims/purpose

* Study population and sample size

* Methodology/methods

* Nursing student program (registered nurse [RN] or registered/licensed practical nurse [RPN/LPN])

* Category of patient safety error or near miss

* Reporting of the error (by the student; by someone else).

Presentation of the results

The results of a scoping review will be presented as a diagram or table of the data extracted from the included papers. The diagram or table will display the type or category of patient error (e.g. harm or near miss) and the number or errors tallied within the respective nursing programs (RN or RPN/LPN). As well, a narrative summary will accompany the diagrams and/or tables and will explicitly address the question guiding the review. Qualitative data will be synthesized within the narrative summary.

Appendix I: Data extraction form

References