Aims and objectives: The Critical Nursing Situation Index (CNSI) is a checklist to detect nursing protocol violations. The objectives of this study were to determine incidences and severities of nursing protocol violations and to check whether corrective actions were taken. Design: Prospective observational audit. Methods: This study was performed in the Intensive Care Unit of the Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands. The CNSI was applied in the period February 2009 to February 2010 by 14 purpose-trained nurses whose interrater reliability had proved sufficient. The checklist addressed nine domains of nursing care: Basic care, Circulation, Respiration, Digestive tract, Infection, Invasive catheters, Medication, ECMO and Central nervous system. The trained nurses also recorded whether violations were discussed with the bedside nurse, whether they could be corrected; and whether they were justifiable. Protocol violations are justifiable when protocol adherence carries greater risk of harm to the patient. Results: Protocol violations were identified for 987 of 8107 items (12·2%) checked in 238 observations in 126 patients. The percentage of protocol violations varied from 5% in the Medication domain to 26% in the Digestive tract domain. More than fifty percent (53·4%) of all protocol violations were corrected in the same shift; 22·3% of all protocol violations proved justifiable, however, these were rarely documented (6·4% of cases). Nurses' classification of the severity of the protocol violations was not reliable because linearly weighted kappa varied from 0 to 0·33. Conclusions: The CNSI is a useful tool to monitor and correct nursing protocol violations. Relevance to clinical practice: Timely identification and correction of protocol violations will reduce possible adverse events resulting from these violations. Furthermore, this study made us aware that protocol violations may be justifiable in clinical practice provided they are well documented.

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Keywords Errors in ICU, Paediatric intensive care, Paediatric intensive/critical care, Practice development, Protocol development, Quality improvement
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Journal Nursing in Critical Care
te Beest, H, van der Starre, C, Tibboel, D, & van Dijk, M. (2013). Nursing protocol violations: Detect, correct and communicate. Nursing in Critical Care, 18(2), 79–85. doi:10.1111/j.1478-5153.2012.00533.x