Missed Care in Hospitals: A Root Cause We Need to Address

Unintentional medical error is estimated to be the third leading cause of death in the United States (1), an alarming statistic that many clinicians dispute because such instances seem so rare in our own professional practice. The majority of these statistics are not the result of those very clear "errors of commission", such as performing surgery on the wrong limb, infusing incompatible blood transfusions, or administering medications to the wrong patient. Rather, most of the roughly 250,000 deaths that occur each year are due to errors of omission, meaning that care was supposed to be delivered, but was not.

When we consider errors of omission, we usually think about diagnostic studies a physician may have failed to order, or a medication that was not given in the correct timeframe. But far more often it's the routine nursing care in hospitals that is missed. Over the past 10 years, there has been a growing body of evidence that suggests that missed nursing care, also referred to as rationed or unfinished care, is a much more common cause of poor outcomes than most executives realize. Such errors can be insidious and are difficult to measure, but they can easily result in pressure ulcers, falls, hospital-acquired infections, increased length of stay, and a host of other issues (2).

In 2009, Beatrice Kalisch developed the MISSCARE tool, a qualitative survey that asks bedside nurses, anonymously, to identify the type and frequency of care that is being missed and the reasons why (3). This tool has been reliably utilized in multiple subsequent studies, and the results have been quite consistent: nurses across the globe report that they routinely "ration" basic nursing care, and miss tasks such as ambulation, turning, and mouth care more than 50% of the time. The most frequently reported reasons for missing such care are lack of adequate staffing, material resources, and teamwork.

An even more significant component of care that is missed by nurses more than half of the time, especially in medical-surgical units, is planning care. The development of an individualized, multidisciplinary plan of care is a CMS requirement, and the ability to effectively coordinate care, evaluate outcomes, and collaborate with the rest of the care team to revise the plan, is a professional expectation of registered nurses (4). However, the bedside nurse is routinely missing from multidisciplinary rounds in most hospitals, and the advent of the EHR has made it possible for physicians and other providers to make changes to the plan without the nurse even being aware. Is it no wonder then, that we continue to struggle with improving quality outcomes and reducing patient harm?

The complexity of the care environment has overburdened nurses to the point that they have no choice but to ration the care they provide, because there is no way everything can effectively be accomplished in one shift. Leaders often suggest that this is due to complacency or apathy, a feeling that nurses are all too aware of. This then leads to disengagement and burnout, which then further worsens the staffing problems most hospitals face, and leads to more rationed care.

It's time we start truly examining not only the root cause of errors that are committed, but also why necessary care is omitted. The MISSCARE survey is an easy tool to administer and an excellent way to get an idea of what is really happening (or not) in hospitals, and why. The results of the survey can provide an eye-opening understanding of many of the root causes for undesirable quality outcomes that most leaders are unaware of.

As we all know by now, it's usually the system, and not the people, that needs to change. Blaming nurses for the inability to provide all of the care they are expected to is definitely not the solution for this, but it is critical that they be involved in the analysis of the data that is collected and the implementation of strategies to prevent the omission of necessary patient care.


1. Makary, M. A., & Daniel, M. (2016). Medical error: The third leading cause of death in the US. BMJ (Online)353.

2. Kalánková, D., Žiaková, K., & Kurucová, R. (2019). Approaches to understanding the phenomenon of missed/rationed/unfinished care: A literature review. Central European Journal of Nursing and Midwifery. University of Ostrava.

3. Kalisch, B. J., & Williams, R. A. (2009). Development and psychometric testing of a tool to measure missed nursing care. Journal of Nursing Administration39(5), 211–219.

4. American Nurses Association. (2015) Nursing: Scope and standards of practice. Silver Spring, MD.

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