What can we do to change this to prevent errors? - page 2
We have all noted, an example on News even on this board, of some major error that has impacted lives. None of us can imagine purposely making a mistake that could kill someone, but under the right... Read More
Nov 8, '07Quote from Emmanuel GoldsteinI do this too! We have scanners where I work, so those help us to catch a lot of errors, but they still are not perfect. The computer system requires us to have another nurse cosign high risk meds such as insulin. One time I had to hang heparin during an emergency situation (my patient was stroking) and the pharmacist was busy in a code (which was in the next room...that was one bad morning!) and was not able to double check my calculations, so I grabbed the nursing supervisor who was on our floor for the code and I made her double check everything with me and chart that she had done that.Second is that we must follow protocols when administering high-risk meds. Insulins, PCAs, heparin drips, epidural infusions, narcotic wastes, etc., should always be double-checked with another nurse. I can't count the number of times I've pulled another nurse aside to witness these things, only to have them sign off or simply nod and walk away without really checking. And then they look at me like I'm nuts when I insist they double check or watch me waste. For anyone that is simply going along and feels they can 'trust' their co-workers to do the right thing, remember that in many cases YOUR name is on the record as double-checking dosages, etc.
Nov 8, '07As a RN whose husband died of a "medical incident" (see my previous posts/threads) I feel that what would prevent errors would be hospital/clinics being required to report all near mistakes and all errors and incidents to a no fault reporting system. Until we compile a base to identify how mistakes happen, take real steps to prevent it from happening again and educate the medical staff how these mistakes are occurring, they will continue to happen. The let's sweep them under the rug and not discuss them ensure the error will happen again and again. Staff inservice needs to be held on a regular basis to pass this info of how other medical incidents have occured and how to avoid them. This is one of the many ways error can be prevented. Prevention is the key but it can't be used until the lock is identified.
Nov 8, '07In addition to adequate and safe staffing as noted in previous posts there needs to be a cultural change in which errors, that are due to system/ process deficiencies are treated as system error and not looking for some one to sacpe goat and punish. Human beings are not infallaible (neither are bar codes). Punishing some one for an "honest " mistake or system error in the long run is counter productive. Errors are not reported or are covered up and the opportunity to prevent similar errors in the future is lost. Private industry and manufacturing have learned this long ago and have made significant improvements in safety by adopting a culture that doesn't punish these types of errors. Error prevention is the key and this requires openess in order to determine the exact cause(s) of the error. Typically it is a series of mistakes the result in bad outcomes.
Now this, non punishment, does not include errors that result from deliberately by passing safety processes and checks.
Nov 8, '07I would much rather spend my time taking care of my patients , giving the right meds, expected and ordered cares and treatments, than looking for other people's mistakes. BUT I do check my meds, and in fact , the protocol to prevent med errors is in place for this to happen. The chart check s for 24 hours against the new mars and 24 hours orders help prevent many errors. Those of us who have been in nursing , or worked in small rural hospitals where WE basically are the pharmacist who mixes the meds, know how far we have come with just unit dosing. We used to get a 3 day total dose of a med in bottle, if it were dc'd prior to that time we threw it in the box for pharmacy. This led to much borrowing, if a patient came in that needed the same med, and it would not come from pharmacy for awhile or was not allowed in the "stock"meds that we were allowed to care, Also led to lots of mistakes, patients were charged for the 3 days worth, and then what was used(or just gone) from the bottle was still charged to the patient when returned to the pharmacy. If there were any left, appropriate credits were made. (many times to the wrong patient. All of us develop our own system of checking our meds, to organinzing our days, to prioritizing(within guidelines) and yes I have taken care of 12 patients.In addition, I have learned through the years, just because it is charted or initialed, it is not necessarily done. Like others, I too have seen too many just signe their names, and not really look, whether it be hang blood, checking pcas, etc. Not to be cliche, but the panic diminishes, the mistakes lessen, and your sense of confidence increases, and with this everything starts to fall into place, and although the days are still too short and the duties too long, we become accomplished nurses, who tend to our patients with educated skill, knowledge, and security.
Along with all this comes the ability to recognize when we are in over our heads, and when to compromise to refuse assignments that are beyond our scope of practice, I wil continue to check my meds, wash my hands, and wear gloves. I will continue my detailed notes, keeping up on all that is going on on my pts, and those I supervise. IT is who I am, and the way I see myself as a nurse. I manage 5 kids at home, 3 who are 14, 16 and 17, and find that much more difficult and mentally tiring.