The incidence of nursing non-vigilance and diminished nursing vigilance in selected cases investigated by the Ohio Board of Nursin

This study described behaviors of registered nurses demonstrating nursing non-vigilance or diminished nursing vigilance in 30 cases of nursing practice breakdown investigated by Ohio Board of Nursing. Data were collected with Taxonomy of Error: Root Cause Analysis and Practice Responsibility (2002) instrument. Behaviors were categorized as nursing non-vigilance when data were present in the category, Lack of Agency/Fiduciary Concern; or as diminished nursing vigilance, if data were absent in the previous category, but present in at least one of the following categories: Lack of Attentiveness/Surveillance; Lack of/or Faulty Intervention; Inappropriate Judgment; Lack of Prevention. Ten cases involved 18 non-vigilance behaviors, and 20 cases featured 35 diminished nursing vigilance behaviors. Nursing non-vigilance behaviors included: missed/diminished sense of patient safety; deliberately covering up errors; failing to notify healthcare provider. Diminished nursing vigilance behaviors included: poor judgment about medication administration; lack of attentiveness; using faulty logic. Research and practice implications are discussed.