Operational failures detected by frontline acute care nurses

Kathleen R. Stevens, Eileen P. Engh, Heather Tubbs-Cooley, Deborah Marks Conley, Tammy Cupit, Ellen D’Errico, Pam DiNapoli, Joleen Lynn Fischer, Ruth Freed, Anne Marie Kotzer, Carolyn L. Lindgren, Marie Ann Marino, Lisa Mestas, Jessica Perdue, Rebekah Powers, Patricia Radovich, Karen Rice, Linda P. Riley, Peri Rosenfeld, Linda RousselNancy A. Ryan-Wenger, Linda Searle-Leach, Nicole M. Shonka, Vicki L. Smith, Laura Sweatt, Mary Townsend-Gervis, Ellen Wathen, Janice S. Withycombe

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses’ direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses’ detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability.

Original languageEnglish (US)
Pages (from-to)197-205
Number of pages9
JournalResearch in Nursing and Health
Issue number3
StatePublished - Jun 2017


  • Medical-surgical nursing
  • Operational failures
  • Organizational learning
  • Patient safety
  • Process improvement
  • Quality improvement

ASJC Scopus subject areas

  • General Nursing


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