ACORN September 2018 Journal EDITORIAL
Missed care is often described as an ‘error of omission’ and refers to nursing care that is needed
but delayed, partially completed or not completed at all1. There is an increasing weight of evidence
pointing to missed care as a widespread phenomenon that poses serious implications for patient
The prevalence of missed care is reported in a review and metaanalysis of the literature, where the
authors found between 55 and 98 per cent of nursing staff missed one or more cares2. Missed care is strongly associated with poorer patient satisfaction3 and, more recently, has been linked to a seven per cent increase in the odds of a patient dying within 30 days of admission to hospital4.
In a study of 1300 hospitalised patients, Baker and Quinn5 found a failure to provide fundamental
nursing interventions such as oral care, head elevation and deep breathing resulted in an increased
incidence of hospital-acquired pneumonia. A recent systematic review reported associations between
missed care and medication errors, bloodstream infections, pneumonia, urinary tract infections, nosocomial infections, patient falls and pressure ulcers6. In the context of perioperative nursing, Duff7 reports missed care in the perioperative environment including a frequent failure to record temperature and provide forced-air warming. Predictors of missed care include youth (<35 years), qualification level, absenteeism within the last three months, limited professional experience and workplace type8. Same-day missed care events can also lead to further missed care events due to the accrual of work demands across shifts9. As causes of missed care are still emerging,
identifying simple, cost-effective solutions for reducing missed care has proved elusive. Increasing
nursing time was reported to have no effect on lowering missed care incidence in one multisite US
study10. However, in a Korean study, increasing nursing hours lowered rates of missed care11. A train-the trainer intervention reduced missed care in a North American study although the authors relied on self reported survey data12. Improving the knowledge13,14, educational level15,16 and research literacy17,18 of perioperative nurses.
The Australian College of Perioperative Nurses (ACORN) is one of the leading global voices in setting
standards within the perioperative environment19–22 yet, based on the literature about missed care, it is
likely that many of these standards are not met during routine care each day. Clinical standards are typically effective as the sum of their parts and rarely work when implemented as a series of missed components of care. Future standards development in the perioperative setting must account for the issue of missed care by acknowledging mechanisms and processes for assuring full implementation wherever possible.
Although solutions are still being sought, it would be naive to think the issue of missed care can be
solved by introducing a single tool, another checklist or even a budgetary injection. The reality
is that perioperative nurses practice in an increasingly complex environment. Issues such as missed
care require an acknowledgement of this complexity by continuing to search for and communicate
effective, stakeholder-informed solutions in environments where quality improvement processes are
embedded, iterative, recursive and ongoing.
References Refer to ACORN Journal
Associate Professor Nicholas Ralph
PhD, MClinPrac (Perioperative Nursing), RN
School of Nursing and Midwifery, University
of Southern Queensland
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