Improving as one culture

There have been a few great articles lately discussing the culture around medical and nursing mistakes, the costs they incur, and the effect that they have on patients and health care workers. Last week, the Obama administration unveiled a partnership that is estimated to reduce billions of dollars in healthcare costs and save 60,000 lives.  Per the article there are nearly 100,000 deaths from preventable medical errors every year.  The idea of this public -private partnership is one that has so much promise.  In the age of technology and information sharing every healthcare organization should be looking to see what others are doing to improve patient care and safety; what works and what doesn’t. This initiative pushes for communication and collaboration improvement at institutions across the country and has the potential to meet its goals of saving lives.

In the years that I worked as a travel nurse I worked at 6 different hospitals. In my professional career overall I have worked at 10 hospitals. Every one of them has systems in place for patient care tasks such as: medication administration, blood administration, patient identification, preparing patients for surgery, and medical procedures (CT placements, central lines, etc) however between hospitals these systems are not usually the same.  This can be confusing to patients as they go to different hospitals for different specialty procedures and set staff up for errors as they work with different organizations during their training and establishing professional careers.

While I have been working, over the years I have seen mistakes happen and I have made a few myself.  I’m not sure if the word fortunate is appropriate, but I feel fortunate that the medication errors that I have made have not had negative impacts or outcomes for patients and they have been immediately correctable. Every nurse has stories about errors that have happened at the bedside.   Historically, the culture surrounding mistakes in the american health care system is not one of transparency and the response to errors made at the bedside surrounding or involving patient care has been punitive.  Who made the mistake and who is to blame for it? Only recently has the idea changed to examine healthcare delivery systems.

A few years ago I was working at a teaching hospital on the east coast in a Surgical ICU. At 630 pm I was walking into the unit for my second night in a row and saw everyone run into the room of the patient I had the night before with the crash cart in tow. The patient was elderly lady and had a thrombectomy of a major abdominal blood vessel in the OR the day before. She was still on the ventilator and had an open abdomen.  As I was walking up to the room I saw the patient’s heart rate was 220 and her systolic blood pressure was 330.  Everyone was in the room trying to figure out what was going on- the patient had norepinephrine infusing continuously ( she was hypotensive after the OR) and some other IV fluid and sedation infusing continuously.  As I watched the entire situation from the doorway- the norepi infusion was stopped and the HR and BP stayed up. They gave IV medication to bring down her HR and BP: Metoprolol, Esmolol, and increased sedation, analgesia and still her HR and BP remained unchanged. They stopped all the IV pumps and looked at what was going in and found the nurse had hung another bag of Norepinephrine as a secondary accidentally instead of an antibiotic.  The remainder of the night we were very busy working to support her heart function and breathing.  She made it through the night and a week later when my contract ended at that hospital she was still there in the ICU.

This is the perfect example of a health care delivery system to examine for where the breakdown occurred and what should change so it wouldn’t happen again.  When you look at the situation from the outside it is easy to assign blame; the nurse made a mistake and it was her fault. When you examine the systems in place you can see this was a mistake waiting to happen. At this hospital all of the medication and antibiotics came in the same size IV bag. The blood pressure medication, the antibiotics, sedation, and insulin from the outside all looked the same and were the same size-100ml. You had to read each label very closely before administering.  Other hospitals standardize medication bags per the medication and color code the labels.  It’s another line of defense. The nurse in this specific situation had grabbed an IV antibiotic and a bag of norepi for her patient at the same time and just hung the wrong one.  There weren’t any other signals in place to clue her in to the mistake she was making and keep it at the level of a near-miss occurrence.

I left this institution a week after this happened. The nurse had worked there almost 20 years.  I know there were punitive discussions around the situation and the nurse.  I don’t know if anyone examined the system itself and to this day I don’t know if anything changed as an effort to improve patient safety. I have to hope it did.

While it is easy to place blame and walk away it is so important to look at the things that need to change within a system to prevent situations like this.  It is considered that if it happened once there have been numerous more near-misses.  As graduation time approaches and new licensed professionals start work it so important to educate on best practice and why institutions have specific systems in place whether it is bar-coding medications and patient ID bands, if it’s 2 person verification, or time outs at the bedside before procedures are done. We need to discuss openly about not taking shortcuts or stepping around these safeguards. We need to keep the culture of patient safety moving forward and improving.  We need to talk openly to new staff that mistakes happen and that they aren’t alone- but that we as an organization are trying hard to prevent any mistakes from occurring.  We need them know the importance of being upfront so errors can be corrected quickly.

What are other patient safety situations that you have come across? What are other systems that are in place that are working within your institution or what isn’t working well? This is such an important topic and I would like to spend a bit of time discussing it.  I think it is important to create a culture of discussion around errors rather than allowing silence to build into shame and secrecy.

Comments

2 comments on “Improving as one culture”
  1. Bruce S says:

    You’re right about what you wrote about. Yet, I’ve chosen to respond by saying so many more people are helped, so many lives are made better compared to lives damaged or destroyed, by nurses and other medical personnel, that human beings do a helluva job caring for others.
    Sure, we all could do better; and, we do great by people, including people who care little about themselves. We, nurses, fix people, improve their lives, or slow their deterioration, often without efforts made by the patient, that it’s perhaps a miracle that more people don’t die, and die more quickly than they do.
    It’s obvious your heart is in your work, and in your caring. Mine was too. Unfortunately, intentionality isn’t all. We’re humans; we make mistakes. In our better moments we learn from them.
    Maybe we need to slow down; take a few slow deep breaths; consider the good we do, and we’re going to do, over and over again. Then, focus on the task at hand, really focus on this moment, in this moment; then, focus on the next moment in that moment. Consider our frailty, our humanness, our imperfections. Then, knowing that we can, and do, make mistakes, in our humility and grace free ourselves from the burdens and suffering created by having to be perfect, grab that bag of antibiotic, and only that bag, and complete the task involved in getting that bag hanging and dripping and infusing into that patient who depends on us, because she must, and trusts us, because we deserve it, and make her life that little bit better in that moment before we move into the next moment to do the next thing for her out of love, compassion, and caring.

  2. I completely agree with you. I really appreciate your viewpoint- Thank you so much for sharing! It is unfortunate to me that these situations of medical errors are what we remember of professionals no matter how long they have worked for without making 1 mistake. We are only human.

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