[sbic56]

Originally Posted by Blackcat99

I think some nurses don't report other nurse's med errors because they don't have the time to do so especially if one is working LTC. If you are the nurse who discovers a medication error you are "punished" for discovering it since you are then required to fill out all the paperwork, call the doctor etc. etc. etc.

I think I understand what you are saying. If there is no review system in place and no research completed as to why the med errors occurs, the the system is useless. My thinking is that the extra effort that is taken to recognize/report the medication error, needs to be followed up in such a way that future errors of that type are avoided. Often the system is at fault, but cannot be corrected unless the problem is exposed. Learning by mistakes, whether your own or someone elses is the way to avoid future mistakes, thus reduce errors and the need to make out more time consuming reports. Safer care for the pateint is the ultimate desired result, right?

[pickledpepperRN]

Link to book To Err is Human - http://www.nap.edu/openbook/0309068371/html/

The JCAHO on errors. Interesting testimony:
http://www.jcaho.org/news+room/on+ca...leary_test.htm


• Protecting and supporting - rather than punishing - caregivers who make errors. When caregivers feel safe, patients are more likely to be safe because such strategies create opportunities to truly learn from identified errors.
• Incenting and promoting counter-cultures of safety. This is a non-delegable responsibility of organizations leaders; those having the courage to rise to this challenge should be rewarded.
• Expanding the applied knowledge base and training of future generations of clinicians to include systems thinking and analysis and training - tried and true approaches used in other high-risk industries to improve safety.
Dr. O’ Leary,… “Most health care errors and even serious adverse events are not made known to organization leaders. This is principally because health care professionals involved in such occurrences are deeply shamed and, at the same time deeply fearful of the humiliation and punishment that all too often has been the knee-jerk response to human error by organization leaders as well as by professional licensure boards and state and federal quality oversight bodies.

In truth, if responsibilities are to be assigned, they have lain, and continue to lie, with organization leaders in assuring that safety is prospectively (and today retrospectively) built into all vulnerable organization systems and processes that have the potential to impact patient care. Humans, including health care professionals, will always make errors. The goal, we now understand, is to prevent those errors from reaching or affecting the patient. And the continuing challenge for all of us is to leverage and incent health care organizations and health care professionals to invest in these preventive efforts.”…

[DusktilDawn]

Excellent links Spacenurse!!

[caroladybelle]

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.

When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.

While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

[DusktilDawn]

Originally Posted by caroladybelle

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.

When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.

While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

I agree. When it is clear that a person is persistently shoddy in their care there needs to be a process in place to prevent these people from causing continued harm to their patients. Anyone go over your boss' head concerning this person?

[sbic56]

Originally Posted by caroladybelle

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.

When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.

While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

That's the dilemma; the rare bird like her. There is the safety issue when the nurse is just plain dangerous in her actions. So, what I am saying is, handle the med errors in a non-punitive way, but let staff know that there are certainly repercussion for continued shody, dangerous practices and let the overall evaluation of the employees work be the guide to whether or not they are competent to care for patients.

I know there has to be a line, but I so hate to have a "ticker" going, so to speak, where there is that atmosphere of impending doom where the nurse thinks, "oh, no....one more med error and I'm a gonner" as, 1)there is going to be another med error and that in itself shouldn't determine a nurses competency 2) she may fear reprisal and not report it in the first place.

I agree there has to be some kind of process in place to maintain the safety of the clients, but the staff need to feel secure in knowing that making a few med errors is not going to mean they are being closely watched until the the next one comes along. That is atmosphere is horrible to work in and is ineffective in reducing medication errors.

[mydesygn]

Originally Posted by caroladybelle

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.

When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.

While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

In Texas, the Board of Nursing promotes the practice of internal peer review. For instance, a nurse who has made 3 minor errors or major errors is taken to peer review where staff nurses review the errors and the nurse's practice and make recommendations regarding reporting to the Board, more education etc.. The primary reason for this is to prevent the BON from becoming bogged down in investigating minor errors. If done correctly, situtions like the one you described would have been prevented since the nurse would have gone before peer review and subsequently reported if necessary. However, any system is oopen for abuse, sometimes "sham" peer reviews can result as a way of punishing nurses by bringing them to peer review for any minor error.

In one of the facilites I worked at peer review was used in such a manner. There was a "no tolerence" attitude. I know of several instances that nurses did not report errors in their own practice or someone elses because they did not want them to get in trouble. These were typically minor errors but unfortunately they continued because the root cause was never addressed and the errors remained unreported. It was just a matter of time before a major incident occured.

[DusktilDawn]

Originally Posted by mydesygn

In Texas, the Board of Nursing promotes the practice of internal peer review. For instance, a nurse who has made 3 minor errors or major errors is taken to peer review where staff nurses review the errors and the nurse's practice and make recommendations regarding reporting to the Board, more education etc.. The primary reason for this is to prevent the BON from becoming bogged down in investigating minor errors. If done correctly, situtions like the one you described would have been prevented since the nurse would have gone before peer review and subsequently reported if necessary. However, any system is oopen for abuse, sometimes "sham" peer reviews can result as a way of punishing nurses by bringing them to peer review for any minor error.

In one of the facilites I worked at peer review was used in such a manner. There was a "no tolerence" attitude. I know of several instances that nurses did not report errors in their own practice or someone elses because they did not want them to get in trouble. These were typically minor errors but unfortunately they continued because the root cause was never addressed and the errors remained unreported. It was just a matter of time before a major incident occured.

There needs to be a medium between working to improve medication safety for the patient while avoiding the "witch hunt" mentality. I worked with one seasoned nurse whose FIRST medication error was a WHOPPER that involved a heparin gtt. This was a concscientious, caring, hard working individual, but alas she is human. Fortunately there was no harm to the patient, but the doctor was demanding her head, referring to her as incompetent. Funny thing, when I started working at this facility, 2 nurses had to verify if a heparin gtt was set properly. When this incident occurred, that policy had been changed so that you did not need another nurse to verify the gtt rate. Funny though, policy changed when staff was decreased prior to this incident. I think because no harm befell the patient is the only reason this person was not crucified, and is still practicing.

[NRSKarenRN]

The Institute for Safe Medication Practices has much info on this topic.

We offer a wide variety of free educational materials and services on our website (www.ismp.org):

• Special Medication Hazard Alerts
• Searchable information on a wide variety of medication safety topics
• Answers to Frequently Asked Questions about medication safety
• FDA Patient Safety Videos
• Three Pathways for Medication Safety Tools:
  a model strategic plan for medication safety , risk assessment tools and
  questions for clinicians
• readiness assessment for bedside bar coding
• White papers on bar-coding technology and electronic prescribing
• A monitored Message Board to share questions, answers, and ideas.

Also, free nursing newsletter that is top notch! I disseminate to all the staff at my homecare agency.

[sbic56]

Originally Posted by NRSKarenRN

The Institute for Safe Medication Practices has much info on this topic.

[/list]Also, free nursing newsletter that is top notch! I disseminate to all the staff at my homecare agency.

Fantasic site, Karen! I like the message board idea. What better way to avoid an error than to learn by others mistakes or near misses? Perfect.