1) I expected to learn about errors and near misses with
patients in the healthcare setting.
2) I learned just this and more about specific case studies
that were so devastating, I don’t think I will ever forget about them! (This is
a good thing because it will always remind me to slow down while giving care to
patients.) I first watched a playlist movie on the Nursing 4550 Quality and
Safety page (Stop MICRA, 2014). It was about Dennis Quaid, his wife, and twins
they had long awaited for and were finally born. Both twins developed a staph
infection soon after birth and were admitted to the NICU. A nurse accidentally
gave a dose of heparin ten times the ordered dose to clear the twins’ lines.
The twins were basically bleeding out and unable to clot their blood.
Miraculously, they survived, but their stay was extended much longer and their
parents had to deal with this traumatic experience. After the event, Dennis
Quaid decided to let this information out to the public in hopes of preventing
human medical errors in the future. The interviewer on 60 Minutes had even
asked the pharmaceutical company why the adult Heparin vial and pediatric vials
were so similar—and how come they were not recalled after wards. The
representative of the pharmaceutical company basically said it wasn’t their
fault and nurses need to carefully read labels before administering medications.
I agree with this statement, but I also can see how these
types of errors occur. Human Factors Theory refers to “the relationship between
human behavior, system design and safety this is becoming increasingly
influential in helping us understand the causation of errors, accidents and
failures in health care systems” (Royal College of Nursing, 2015). There are three main factors that can
attribute to human errors, namely job, individual, and environment. Individual
nurses may be fatigued, feel rushed, or lack certain training when caring for
patients. The system at the hospital may not have many safety rules or
procedures to follow. The environment may be dimly lit, chaotic, or lack
necessary machines to do one’s job effectively (or the technological equipment
is in need of repair). These all contribute to how safely a nurse will render
care to her patient. To help solve these problems, risks need to be identified
in each of these areas to help prevent potential errors before they occur—because
in healthcare, errors that do occur can result in accidental death.
3) I was saddened and surprised after reading the case study
(Johnson, Haskell & Barach, 2016) that we discussed as a group. A nurse
spiked an enteral feeding bag with IV tubing and administered it to a pregnant
patient through her PICC line. The patient was supposed to receive TPN which is
compatible with a PICC line and yellow in color. (Vastly different from
brownish-gray feeding tube solutions). The patient’s baby died from excessive
fat clogging its vasculature, and the patient also coded and died soon after.
The error of administering an enteral formula via the patient’s intravenous
line was not noticed for 6 entire hours. During this time, the formula
continued to infuse and cause the patient to experience more pain and
difficulty breathing. The patient’s family was not notified that the error had
occurred until the very last minute. In addition, the deceased patient left her
husband a widow to raise his 3-year old son alone.
The case study was written by the patient Robin’s mother,
Glenda Rodgers. She was a Registered Nurse herself with many years in
obstetrics. From Glenda’s perspective she wishes to this day she would have
questioned more what was going on with her daughter so they could have
intervened earlier and potentially saved Robin’s life. Glenda wonders if she
was too trusting. Glenda ended her account by stating that if patients and
families are asking questions, they are not questioning your ability and
authority as a nurse. They are genuinely concerned, and as their nurse, you
should be as well. Diligently seeking out and finding a resolution to questions
can help save patient lives.
I also learned about Just Culture. Traditionally, healthcare’s
culture has held individuals accountable for errors and mishaps that befall
patients under their care. In contrast,
a Just Culture recognizes that individual practitioners should not be held
accountable for system failings over which they have no control (American
Nurses Association, 2010, p. 2). A culture that focuses on “no blame” helps
clinicians feel more safe and open about reporting errors and near misses that
occurred. This way, risk management teams can learn of the errors/patient
harms, and intervene quickly by new process implementation, in hopes of
preventing the reoccurrence of the event. This leads to better patient safety
outcomes and improved processes in a healthcare system.
4) I plan to admit near misses by filing out incident
reports. I also plan to slow down when caring for patients, more diligently
seek out answers to patient/family concerns, and always follow policies and
procedures I’ve been trained on. (If I have not been trained on something, I
will openly communicate that with my charge nurse and find ways to safely care
for the patient within my scope and with other nurses’ help if needed). I will
continue to ask questions when in doubt as well—this is a practice I have
always strived to do anyway.
5) I enjoyed this unit immensely. Yes, it was very
disheartening to learn about, but reading the cases helped instill important
lessons in my mind of listening to and valuing patient concerns. If something
doesn’t feel right with a patient, I will further assess the problem to find
the safest solutions for the patient.
References
American Nurses Association (2010). Position statement: Just culture. Retrieved online from http://nursingworld.org/psjustculture
Johnson, J. K., Haskell,
H. W., & Barach, P. R. (2016). Case
studies in patient safety: Foundations
for core competencies. Case 18, p. 231-245. Burlington, MA: Jones & Bartlett Learning
Royal College of Nursing (2015). Human factors in patient
safety. Retrieved online from https://www.rcn.org.uk/development/practice/cpd_online_learning/making_sense_of_pati ent_safety/human_factors_in_patient_safety
Stop MICRA (2014). Dennis Quaid talks about his twins and
medical negligence. Retrieved from https://www.youtube.com/watch?v=GEDMYsm3Nxs&index=7&list=PLUuOgSK- 0gzFyneo6CVElbN1wWLO1YGth
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