Should we use the word fault?

When I first posted about a week ago, wanting to start an honest and transparent discussion about medical errors, I really was not expecting to have stories pop up in the news to talk about.  I really expected to discuss this topic with a mix of general experience, policy, institutional procedure, national regulations, and personal flair.  It is hard to be excited about the fact that in the Pacific Northwest there have been 2 stories reported in the news this week, about this very topic.

I have debated about postponing any further posts on this topic for now after the tragic news yesterday- but while these stories are relevant we should examine them.

In The Seattle Times,  it was reported that an Oregon surgeon operated on the wrong eye of a 4 year old patient.   The article was vague and direct as a news source. An operation happened on the wrong eye, while in the OR the surgeon realized her error and did the operation on the correct side and came out and told the boys parents.

I have stated a few times in my writing on here as well as professionally that I don’t like blame and to use the word fault in situations of medical errors.  However, I do believe that people hold responsibility for their actions and the errors they have made.  I feel the exact same about the medication errors I have made. They were easily reconcilable, and without harm, though completely my responsibility. The first medication error I made was starting a dobutamine gtt on a patient I admitted from the ER.  The bag came from the pharmacy and I hung it with an assumption that the concentration of medication in the bag was the standard; it was not, it was quadruple the standard concentration. I hung it @ 6pm and left @ 7. Fortunately, the nurse following me caught it right away.  However, I was written up for it and no one had talked to me about it the next day. I didn’t find out about the error for over a week.  After having made a mistake like that, it’s important for me to discuss it; know that no harm was caused to the patient, and use it as a very important opportunity to learn from the mistake. Also it would have been the best time to create a discussion with the pharmacy as to why a medication was sent so concentrated when I was giving the medication for the first time. That is not common practice. Typically, you start the standard concentration and if you are going up a lot on the medication and the patient is getting a lot of IV fluid then, you increase the concentration so the medication runs at a slower rate.  After this happened, I didn’t get blamed for anything, I just got told about it. No harm was done to the patient, but a learning opportunity and a chance for this hospital’s pharmacy to examine what could be done differently was also missed. So instead, nothing came of it and the problem disappeared into an electronic paperwork filing cabinet and thats it. I took full responsibility to my manager when he approached me about this but I also stated to him that it would have been nice to know at the time so we could all examine the possible improvements that could be made.

I did a little more internet investigation in the Portland, OR news and found more information about the situation.  The physician was not a employee of the hospital though had practice privileges there. She had marked the operative site with a marker prior to surgery and still operated on the wrong side.  The hospital has a surgical procedure checklist discussed by the CEO and that it had been signed off on by the other staff in the OR as well. Where then does the responsibility fall. Did anyone notice that the doctor was operating on the wrong side? Was the surgical site marked, prepped, and cleaned and then she still operated on the wrong non-prepped side? Did she mark the site then prep and operate on the wrong side? Did they notice it when they were done or half way through? As is obvious, I always have a lot questions surrounding incidents like this.  I feel it is so important to remember that these situations are never black or white and the more information that is available after an incident like this the more we all learn.

The American Journal of Nursing had a great story by an RN that I think is inspiring to share. It is so well told.  These instances are so important to share amongst each other professionally.  She tells her story with great feelings and honesty.

As a nurse, over the last few years I really have learned that mistakes happen and that you have to continue to practice as meticulously and with the greatest caution every shift- never letting your guard down or getting complacent. Talking about it is important. I am an advocate of turning mistakes into opportunities to teach. I also feel it is so important to create a culture of honesty and transparency within an organization and helping this culture to flourish by talking to new staff about this topic.

I really hope by creating a open discussion for patients and professionals we embrace the opportunity we have to learn from each other.

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