Errors in hospitals remain a major cause of death.(1) Many patient safety initiatives focus on reducing the risk of potentially fatal errors. Recent research findings remind us that errors of omission—such as missed nursing care—may be as important to patient safety as errors of commission.
Missed care is also termed care left undone, unfinished care, and implicitly rationed care. In reviewing the literature on missed care, Jones and colleagues point out that "few care processes reach patients without first passing through the hands of nurses."(2) Missed care thus represents a form of health care underuse which, argues safety expert James Reason, is the most common cause of quality problems in health care, more so than overuse or misuse combined.(3)
A growing body of research identifies causes and consequences of missed care, primarily in acute hospital settings. The most widely explored cause is low nurse staffing levels. When there are fewer registered nurse (RN) staff on duty, necessary care is less likely to be fully completed.(2) The presence of larger numbers of lesser-trained staff does little to compensate for low RN staffing, because their roles are different.(4) Data from the multinational RN4Cast study found a two-fold variation between European hospitals in the reported incidence of missed care.(5) Missed care has consequences.(6) Our analysis of data from England found that higher rates of missed care were associated with lower patient safety grades reported by nurses.(4) Where missed care rates are higher, patients are less likely to rate their hospital well (7), and there is an increased risk of adverse events and patient falls.(8)
Much of the interest in missed care has been because of the role it may play in explaining the widely observed association between low nurse staffing levels and increased mortality in hospital patients.(6) Over the past 30 years, many studies have reported a relationship between RN staffing and case-mix adjusted hospital mortality. Yet almost all of this evidence has been cross-sectional in design. It is essential to explore the mechanism involved before concluding that it is a cause–effect relationship.(9) One theory is that low staffing levels lead to incomplete care and less patient surveillance, causing delays in detecting and responding to potentially fatal deterioration. According to this theory, missed care is a key mechanism through which nurse staffing has an effect on patient outcomes—a mediator.(10) Findings from the RN4CAST study demonstrating a link between nurse staffing levels and both mortality and rates of missed care would appear to support the theory.(5,11)
Our most recent research has directly tested the relationship between nurse staffing, missed care, and mortality. Based on data from more than 400,000 patients and surveys of 26,000 nurses across Europe, we found that when nurses report missing more necessary care due to lack of time, mortality following common surgical procedures is increased. After adjusting for patient and other hospital characteristics, each 10% increase in reported missed care is associated with 16% greater risk of death.(12) Crucially, this research showed that the level of missed care directly explained some of the observed association between nurse staffing levels and mortality. These results support a causal pathway connecting nurse staffing and mortality. Nurses who have too many patients to care for do not have time to complete all necessary care, and this missed nursing care increases the risk of patients dying in the hospital. Other recent analyses from RN4CAST show a similar finding for patient experience.(7)
The findings have implications for policy and practice. Improving patient safety requires us not just to reduce the risk of mistakes being made, but also to maximize the capacity for nursing care and surveillance to be undertaken—to ensure the mix and number of staff on duty are sufficient to meet patient needs fully, without necessary care being missed. The airline industry adopts risk-control strategies that make explicit the conditions needed to run services safely. If these conditions—including staffing levels—are not met, services are suspended.(13) Such approaches are rare in health care. Workforce policies and practices are needed to minimize the risk of care being missed and enhance patient safety.
In many countries, hospital mortality rates are used to assess hospital performance. In England, high mortality rates led to the detection of serious care failings at the Mid Staffordshire NHS Foundation Trust, causing a national scandal which resonates to this day. Investigations revealed that nurse staffing levels and skill mix had been changed at the hospital, without assessment of the impact on patient care.(14) By the time there was sufficient data and analysis to identify persistently high mortality rates, considerable time had passed, meaning that problems were allowed to persist for years. Monitoring missed care may therefore offer a more sensitive early warning system for hospitals to detect problems before patients die, rather than using patient deaths themselves as the indicator of high-risk environments. Such an approach is already being trialed in Ireland.
Ensuring sufficient staffing to tackle causes of care omissions is a key element in reducing the risk of avoidable harm and improving patient safety. While it is easy to focus on the deficits of individual practitioners, John Stuart Mill's words on inaction apply not just to staff who are unable to deliver complete care, but also to policymakers and leaders who fail to translate research into practice: "A person may cause evil to others not only by his actions but by his inaction, and in either case he is justly accountable to them for the injury."(15) As with so many areas of patient safety, addressing missed care must be considered as a key foundation for a safe system of care.
Jane Ball, PhD Principal Research Fellow University of Southampton Faculty of Health Sciences
Peter Griffiths, PhD Chair of Health Services Research University of Southampton
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13. Vincent C, Amalberti R. Safer Healthcare: Strategies for the Real World. New York, NY: Springer; 2016. ISBN: 9783319255576
14. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London, UK: The Stationery Office; 2010. ISBN: 9780102964394.
15. Mill JS. On liberty. New York: Appleton–Century Crofts; 1859.