What To Do After You've Made A Mistake - page 4

by Ruby Vee

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nursing school doesn’t really teach you how to be a nurse, it just gives you a glimpse into the world of nursing and the nclex gives you a license to learn. if you’re smart, you’ll learn something new every day of your career. ... Read More


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    The ability to identify and correct a error in a meaningful way and in time to make a real difference in regards to patient safety is the most important obligation health-care providers have In day to day operations
    It could to be based on a national guidelines as detailed in the attached documents from the NQF National Healthcare Quality Report, (Ser11)
    NQF’s list of serious reportable events includes both injuries caused by care management (rather than the underlying disease) and errors that occur from failure to follow standard care or institutional practices and policies
    Reporting and the change in policy aka closing the wrong door “No Wrong Door”would be required in H.B. NO. 420 are detailed in the Agency for Healthcare Research and Quality Website (Ser11)
    The information that is obtained from the patient with a focus not on shaming and blaming the care provider allows three things to occur which all hospitals desire
    IMPROVE PATIENT SAFETY
    The gathering of accurate and timely information allows the policy change or no Wrong Door Strategy to be an ongoing and crucial component of daily operations
    JACHO surveys on an annual basis with Chart reviewing that may or may not address the day to day realities in a facility
    DECREASE STAFF BURNOUT
    It does this by addressing the policy or procedure as the bad guy
    The goal is to make it hard to do the wrong thing and easy to do the right thing
    SAVES MONEY
    Dr Ben Ho assistant professor of economics at Cornell Johnson Graduate School of Management, earned a PhD, from Stanford University and Dr. Elaine Liu assistant professor of economics at the University of Houston earned a Ph.D. in Economics, Princeton University, 2008
    at have co-authored Does Sorry Work? The Impact of Apology Laws on Medical Malpractice proving that my mother was right “It pays to tell the truth”
    “It is To date, this paper is the first economic study to investigate the impact of the State-level apology legislation on claim frequency and claim severity.”
    (Ho,2009).
    “We find that in the short run the law increases the number of resolved cases, while decreasing the average settlement payment for cases with more significant and permanent injuries. While having an insignificant impact on the settlement payments for cases involving minor injuries, the apology laws do reduce the total number of such cases. While the short term increase in malpractice settlements could be a surprise to policymakers and advocates of apology laws, we believe this is an artifact of data limitations. Our findings suggest that apology laws reduce the amount of time it takes to reach a settlement in what would normally be protracted lawsuits, leading to more resolved cases in the short run. In the long run, the evidence suggests there could be fewer cases overall. (Ho,2009)
    Dr Steve Kranman is the true pioneer that changed a paradigm back in 1987 He was the anybody and somebody that everybody at the VA would want as a Doctor if they were a patient or had a family member or co worker in harm’s way
    There was a most important job that needed to be done, And no reason NOT to do it, there was absolutely none.
    But in vital matters such as this the thing you have to ask, is WHO exactly will it be who’ll carry out this task.
    ANYBODY could have told you that EVERYBODY knew, that this was something SOMEBODY would surely have to do.
    NOBODY was unwilling, ANYBODY had the ability, but NOBODY thought he was supposed to be the one.
    It seemed to be a job that ANYBODY could have done, If ANYBODY thought he was supposed to be the one.
    But since EVERYBODY recognized that ANYBODY could, EVERYBODY took for granted that SOMEBODY would.
    But NOBODY told ANYBODY that we are aware of, That he would be in charge of seeing it was taken care of.
    And NOBODY took it on himself to follow through and DO, What EVERYBODY thought that SOMEBODY would do.
    When what EVERYBODY needs so did not get done at all, EVERYBODY was complaining that SOMEBODY dropped the ball.
    ANYBODY then could see it was an awful crying shame, And EVERYBODY looked around for SOMEBODY to blame.
    SOMEBODY should have done the job and EVERYBODY would have, But in the end NOBODY did what ANYBOY could have.
    He took a chance and did only 5% of healthcare professionals have ever done, Tell the truth in a way that made the trial lawyer wonder what to do with their sudden loss of clients
    “Dr. Kraman served as Chief of Staff and Chairman of the Risk Management Committee of the Veterans Affairs Medical Center in Lexington, Kentucky, from October 1986 to February 2003. As Chief of Staff, he was responsible for the development, organization, implementation and support of all patient-care activities. As Chairman of the facility’s Risk Management Committee, he was instrumental in designing the risk management and patient safety programs of that institution that was the first to consistently employ full-disclosure of medical errors over a prolonged (16 year) period. The paper that he co-authored in December 1999, established for the first time that full-disclosure was ethically and financially feasible. (Cro11)
    In 2000, Lexington’s risk management program won a Cheers Award from the Institute of Safe Medication Practice, a Scissors award from the Department of Veterans Affairs and was First runner-up for the Frank Brown Berry Prize in Federal Medicine. In October 2002, the facility’s full-disclosure policy won the John M. Eisenberg Patient Safety Award for advocacy sponsored by the National Quality Forum and the Joint Commission for Accreditation of Health Care Organizations. Both Dr. Kraman and his colleague, Ginny Hamm, JD have authored several papers and have been frequent speakers to healthcare organizations on the subjects of risk management, patient safety and how full-disclosure helps protect hospitals and doctors from lawsuits while assuring justice for the victims of medical errors. (Cro11)
    WORKS CITED
    2010 National Healthcare Disparities Report.Agency for Healthcare Research and Quality.[Online]2010.[Cited: 11 March 2011.]http://www.ahrq.gov/qual/nhdr10/nhdr10.pdf.
    Crossing The Quality Chasam 6th Anual VIPC & S Conference on Patient Safety.[Online][Cited: 11 March 2011.]http://www.vipcs.org/conf2006/speakers2006.htm.
    HoBenjaminand Liu, Elaine,Does Sorry Work? The Impact of Apology Laws on Medical Malpractice.Social Science Electronic Publishing, Inc.[Online]Johnson School Research Paper Series ,1 December 2009.[Cited: 22 Feburary 2011.]http://ssrn.com/abstract=1744225.
    Serious Reportable Events .Serious Reportable Events The National Quality Forum.[Online][Cited: 9 March 2011.http://www.qualityforum.org/Publications/2008/10/Serious_Reportable_Events.aspx.
    cherryames1949 likes this.
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    Thank you for your post. As a nurse of 10 years, I recently made a pretty serious mistake-without harm, but will probably lose my job over it. You're right though, about forgiving yourself. Its a vicious cycle, but one I haven't been able to overcome yet.
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    I made a mistake a year ago, 6 months into being a new nurse that had the potential to be very serious. Once I realised the error i reported to the in charge nurse and doctor and ultimately no harm came to the patient. I think about that patient a lot. Your very honest and frank advice about there usually being something that can be done and basically saying i did the right thing after doing the very wrong thing, has been incredibly comforting. Thank you for allowing me to feel human again and allowing me to think perhaps I'm not the very worst nurse in the world.
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    Quote from mhospRN
    I made a mistake a year ago, 6 months into being a new nurse that had the potential to be very serious. Once I realised the error i reported to the in charge nurse and doctor and ultimately no harm came to the patient. I think about that patient a lot. Your very honest and frank advice about there usually being something that can be done and basically saying i did the right thing after doing the very wrong thing, has been incredibly comforting. Thank you for allowing me to feel human again and allowing me to think perhaps I'm not the very worst nurse in the world.
    Everyone makes mistakes. What matters is what we do AFTER we've made one. You did the right thing, so that makes you one of the good nurses!
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    Maybe I'm different, but I just couldn't hide a mistake I made. My conscience would eat away at me. On the occasions that I've made mistakes, I fessed up right away; I couldn't bear if something happened to the patient. I'm astounded that someone would lie like the experiences in this article.
    silverbat and wooh like this.
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    Quote from dudette10
    I also want to add something to Ruby Vee's excellent post.

    Never forget to learn from your "almost" mistakes, too. You know the ones...where you almost make a mistake, but catch it just in time. As a student, I've made a more "almost" mistakes than actual mistakes because I have someone watching over my shoulder, and those are very important to reflect on also.
    So true dudette! We all make mistakes but stepping up and admitting the mistake is the true test. Some people just don't get it.
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    admitting you mistakes is good however the risk of losing your job is a very tough thing to consider
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    Quote from amygarside
    admitting you mistakes is good however the risk of losing your job is a very tough thing to consider
    I would think you'd run a far greater risk of losing your job if you tried to hide a mistake which was later discovered. No one wants to work with a nurse they cannot trust. And I wouldn't want to work with a nurse who wouldn't do the right thing for a patient they may have harmed because they were worried about losing their job.
    bbnursedfw08 likes this.
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    right! but if you get fired on the spot after admitting your mistake, then either ways you won't earn that trust.
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    Quote from amygarside
    right! but if you get fired on the spot after admitting your mistake, then either ways you won't earn that trust.
    Someone smart enough to recognize a mistake and honorable enough to admit it is someone I'd trust more that someone who was either too stupid to realize they'd made one or more committed to covering it up than to mitigating the harm to the patient. We ALL make mistakes.
    OCNRN63 and bbnursedfw08 like this.


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