Travel Nurses: Risk Management Insights

The healthcare sector is struggling with staffing shortages. Travel nurses help bridge the gaps, enabling healthcare facilities to maintain service levels. While the use of travel nurses has been necessary, it has led to new emerging risks. Here are key considerations for healthcare leaders.

Malpractice Risk Factors Differ for Travel Nurses

Coverys analyzed five years of risk data from nearly 7,000 closed malpractice claims and identified more than 12,000 risk management issues. From this data, we identified the following top three areas of vulnerability:

• Critical decision-making.
• Technical performance.
• Clinical systems.

For claims involving travel nurses, the top areas of vulnerability are different:

• Clinical systems.
• Electronic health records.
• Human factors.

Diving Deeper Into the Data

Within the broader risk categories, there are subcategories that help us better understand key claims drivers.

Clinical systems subcategories include:

• Failure to manage the patient’s follow-up care.
• Lack of care coordination.
• Results or specimens that are lost, misfiled, or not brought to the attention of the provider.
• Failure or delay in follow-up or notification of incidental findings.
• Failure to promptly review results.
• Failure to compare previous diagnostic results.

Travel nurses may not be in one place long enough to follow up. They also may be unfamiliar with the organization’s specific procedures or communication mechanisms.

Electronic health record (EHR) subcategories include:

• Documentation issues.
• Lack of an active or updated medication list or allergy-related documents.
• General EHR usability.

Human factor subcategories include:

• Failure to function as a cohesive clinical team.
• Cultural or organizational vulnerabilities.
• Failure to ensure a safe environment with adequate staffing.
• Workplace design.
• Distractions or a lack of situational awareness.

It is easy to see how these risks might be higher with travel nurses. They may find it difficult to adjust to documentation guidelines or to form a cohesive team in the short time they are working for an organization.

How These Risks Affect Patients

Although data can provide signals to areas of vulnerability, individual stories illuminate the stakes involved, both in terms of human life and financial loss. Here is one example:

An outpatient dialysis clinic needed to use a travel nurse due to a staffing shortage. Two patient care technicians went on break leaving the travel nurse in charge of 12 patients. The travel nurse did not realize that one of the patient care technicians had moved one of the dialysis machines, causing the configuration to change from patient/machine/patient/machine to patient/machine/machine/patient.

While the travel nurse was administering one of the heparin boluses in the area of the reconfiguration, he realized he was injecting into the wrong patient’s machine. He immediately clamped off the line and checked the patient’s orders. When he was unable to find the patient’s order for heparin, he searched further and discovered the patient had a heparin allergy. The travel nurse went back to the patient and found them to be unresponsive. He called 911, but he was unfamiliar with the emergency protocols and there was a delay in response.

This incident resulted in the patient’s death and a $2 million verdict.

Onboarding Travel Nurses With Empathy

Although travel nurses help relieve staffing shortages, they are not always well received by other team members. Often, staff members associate them with higher costs, which can lead to resentment.
A negative environment can inhibit collaboration and open communication. Travel nurses and the regular staff need to work together to form a cohesive team and maintain an acceptable standard of care amid staffing issues. Therefore, it’s crucial that healthcare facility leaders have programs to help travel nurses acclimate to the new environment.

Onboarding practices must be designed with care. Leaders are encouraged to look at their own event and near-miss data to uncover areas of vulnerability and incorporate relevant risk management measures into onboarding.

Onboarding for travel nurses should cover:

• Electronic health record access to information vital to patient care.
• Documentation expectations.
• A physical tour of the patient rooms and units to ensure travel nurses know where to find supplies during an emergency.
• Chain-of-command policies and expectations.

A mentoring program for travel nurses may also help. A seasoned staff member should be available for questions, similar to the student nurse approach. Beyond this, it’s important to treat travel nurses with empathy remembering that starting a new job in a new area is stressful.

Leaders should prepare their teams for the arrival of travel nurses and ask their staff to make them feel welcome. Conduct surveys of current staff and brief exit interviews of travel nurses to assess the culture and find out how you can make improvements. Finally, leaders should make time to greet travel nurses warmly and offer assistance with orienting them to their new surroundings.

Data-driven risk management systems can help you take control of the unique exposures related to the use of travel nurses, ultimately improving patient safety and outcomes.

This article was based in part on the Coverys presentation Mitigating Risks from Travel Nurses, presented by Susan L. Montminy, EdD, MPA, BSN, RN, CPHRM, CPPS.


Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.