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In rule‐based performance, the clinician applies a learned rule to an appropriate situation. The delivery of health care is largely based on rules, often called protocols. Rules may be learned in nursing school or through life experience, clinical experience, or continuing education. Errors may occur when functioning in a rule‐based performance mode. Leaders need to track data on staff compliance with rule‐based clinical performance and continually look for ways to improve practice. Errors occur in three ways: using the wrong rule; misapplying the rule; and disregarding the rule.

Sometimes, clinicians use the wrong rule. They may have been taught or somehow learned the wrong response for a situation. For example, Donna graduated many years ago and learned to treat patients for hypoglycemia if the glucose was 60 mg/dl or less. If Donna has not kept current with more recent diabetes and hypoglycemia guidelines, she will fail to treat a patient with a glucose of 70. The solution to this type of error is to educate clinicians with the right rule.

A rule‐based error also occurs if the clinician misapplies the rule. The nurse may know the right response but select another response instead. For example, Donna's patient has a blood sugar of 64 mg/dl. Donna knows it needs to be treated. Rather than rely on her memory, she quickly consults the hypoglycemia algorithm—an excellent safety practice. The algorithm indicates treatment with 15 g of glucose. Donna misreads the algorithm and gives 30 g of carbohydrates instead. This could over‐correct the low blood sugar, causing the blood sugar to spike and creating another patient safety event. This type of error may be prevented by pausing and thinking or reviewing a second time.

Rule‐based performance errors may also be caused by disregarding the rule, as when the clinician knows the rule but chooses not to follow it. For example, Donna's patient has a hypoglycemic event and she treats it appropriately. Donna knows that she should recheck her patient's glucose level 15 to 30 minutes after treating hypoglycemia. She sees that the patient is alert and oriented and looks fine. Donna tells the patient to put on her call light if she runs into any problems and does not recheck the blood sugar. Non‐compliance with rules can be prevented in several ways. First, Donna needs to understand the risks involved in not following the rules. In addition, organizations need to reduce the burden or difficulty of following the rules. Nurse leaders need to consider if there are adequate numbers of bedside glucose monitors so that a glucose recheck can be easily accomplished. They need to examine staffing to ensure it is enough to allow time for the glucose recheck. Last, Donna may need to be coached by her manager to make better decisions. If this is a repeated behavior, Donna will need to be counseled and disciplined by a nurse manager.