Errors as Opportunities
ERRORS AS OPPORTUNITIES
The medical
mistake happens more often that we would like. As healthcare professionals, we
chose our profession to help and heal people not to hurt them. However,
mistakes of consequence with adverse outcomes, and mistakes of little
consequence occur every day (Porter-O’Grady and Malloch, 2015).
At my
hospital on the telemetry unit, we had a 35-year-old male patient who needed
intravenous (IV) pain medication to help with his sickle cell pain. The nurse
who was taking care of the patient was extremely busy that morning. The unit
was short of the unit secretary. That meant that nurses were answering phone
calls and call lights. UGH!!!
The patent
called a couple of times for his medications until the nurse was able to
deliver his medication. However, the nurse pulled Dilaudid out of Pyxis and
gave it to the patient without using scanning device. The nurse attempted to
scan medication several times. However, she was unsuccessful. Due to hectic
morning, patient calling several times, and nurse feeling overwhelmed she
proceeded to administer the drug. The nurse reassured the patient that she
would check on him in half an hour. After while the nurse checked on the
patient, and noted that he was unresponsive, with shallow breathing, and lethargic.
Long story short, the patient was transferred to the Intensive Care Unit (ICU)
and had to be intubated.
Apparently,
the patient had severe allergic reaction to Dilaudid. The allergy was
documented in the patient's chart. However, the patient did not have an allergy
band on his wrist, and the nurse failed to use scanning device. If the scanning
device were utilized, it would be impossible to proceed with medication. Each
time when the patient has an allergy to particular medication, the scanning device
will not scan the medication and will show red exclamation sign.
Pat Ebright (2010) webcast regarding the complex adaptive system healthcare resonated with me. In my nursing career, I have seen many system changes. I started my nursing career on a busy telemetry floor. Several months after I started, we began taking post cardiac cath. patients. I was scared to death. We had extensive training, and new protocols/procedures were utilized. However, all the change affected our daily routines, our decision-making process, and daily workflow. Our hospital ensured that we had adequate support while we were adapting to new patient load. For several weeks we had a nurse from catheterization laboratory to assist us and provide support.
Stacking,
peeking, and the blunt end/sharp end are interesting concepts. I never realized
that I use them in my nursing career. For example, prioritizing and juggling
several chores at once is a standard process for any nurse. I believe we can
all relate to those instances when we stayed late to finish charting, or to
finish new admission. Most of the nurses have the list of their daily routine.
Famous "to do list." The difference is how efficient we become
through the list. Pat Ebright (2010) asserts that novice nurses do not move the
list as quickly as experienced nurses. There were many instances that I have
struggled with my list, trying to finish all the tasks. However, with
experience and managing through difficult situations, I persevered and learned.
I am convinced that hands-on experience, supportive environment, and asking
questions is an excellent way to learn.
My hospital encourages reporting of adverse events and potential adverse events. Any occurrences that involves patients, visitors, staff, or environmental issues will be reported using the online Patient Safety Net (PSN) event reporting system. Boysen (2013) emphasizes that open, honest, and non-punitive reporting environment will improve patient safety, promote innovation and cross-departmental communication.
References
https://www.youtube.com/watch?v=IVHbty3iI9k
sustainable health. Burlington, MA: Jones & Bartlett Learning
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