When Nurses Make Fatal Mistakes - page 2

Jessica's Story Jessica was a young, conscientious nurse in her first year of nursing. Jessica was having a typical busy day on Tele. One of her patients, a middle aged male in Room 4152, was... Read More

  1. by   Susie2310
    Quote from Nurse Beth
    I have to say I've never worked in a "just culture" but I believe the intent of a just culture is patient safety.
    Yes, that's understood.
  2. by   TriciaJ
    Quote from Nurse Beth
    I have to say I've never worked in a "just culture" but I believe the intent of a just culture is patient safety. I know whenever I've made a mistake, I punished myself far worse than my nurse manager ever could, or did.

    I think complacency comes from within.
    I agree with you. There is no doubt in my mind a nurse will punish herself much more severely than anyone else can. The current working conditions in many nursing homes and hospitals are errors looking for a victim. The fact that more don't happen is a testimony to superhuman efforts by nurses.

    And yet there are still some of us who don't mind watching fellow nurses being thrown under the bus. That is extremely arrogant and tempting fate.
  3. by   RiskManager
    I do 'just culture' for a living, and although many errors are indeed systems or process issues, there can still be issues of personal accountability for issues within the span of control of staff and depending on the causative factors, if there was significant patient harm, there may be personnel-related consequences for the providers and staff involved. Because this is a nursing board, many members here think this is unique to nursing staff. I deal with everyone from environmental services to physical therapy to lab to imaging to finance to pharmacy to employed providers, and the just culture philosophy is applied across the board. Your mileage, in your facility, may vary from how I do it and we can all agree that there are political and other considerations that enter into it as well.
  4. by   Nurse Beth
    Quote from RiskManager
    I do 'just culture' for a living, and although many errors are indeed systems or process issues, there can still be issues of personal accountability for issues within the span of control of staff and depending on the causative factors, if there was significant patient harm, there may be personnel-related consequences for the providers and staff involved. Because this is a nursing board, many members here think this is unique to nursing staff. I deal with everyone from environmental services to physical therapy to lab to imaging to finance to pharmacy to employed providers, and the just culture philosophy is applied across the board. Your mileage, in your facility, may vary from how I do it and we can all agree that there are political and other considerations that enter into it as well.
    So interesting! My understanding is that it's absolutely not blame-free, rather, accountability is expected from both the employee and the facility.

    Mistakes are differentiated from reckless behaviors, and discipline is based more on behavioral choices than outcomes.
  5. by   Susie2310
    Quote from Nurse Beth

    Mistakes are differentiated from reckless behaviors, and discipline is based more on behavioral choices than outcomes.
    Are you saying that a lighter degree of disciplinary procedures is merited when a practitioner has disclosed their error fully in a timely manner regardless of the patient outcome?

    Mistakes, irrespective of however well intentioned or conscientious the person who made them is, can and do kill and injure patients regardless of whether the practitioner's behavior is reckless or not.
    Last edit by Susie2310 on Feb 15
  6. by   djh123
    I've read recently of a couple of pharmacy errors that resulted in deaths of children. One was something like 1,000 times the prescribed dose. Numbers matter, and paying attention to detail matters. We can't let our guard down, no matter how tired or 'busy' we are, but we all know that sometimes it IS hard to keep focus 100% of the time.
  7. by   Nurse Beth
    Quote from Susie2310
    Are you saying that a lighter degree of disciplinary procedures is merited when a practitioner has disclosed their error fully in a timely manner regardless of the patient outcome?
    Not at all. By behavioral choices, I meant the difference between a nurse who recklessly does not follow procedure and a nurse who makes a mistake despite doing so.
  8. by   Nurse Beth
    Quote from Holt147
    Mistakes are often about the numbers, plus a nudge from poor policies and lack of education.
    Take the standard 50 CC IVPB Antibiotic dose to be given by intermittent IV technique.
    The typical RN will program the IV pumps "volume to be infused" for exactly 50 CCs, and disconnect the patient when the pumps alarm goes off...leaving 56 percent of the antibiotic in the IV tubing.
    His or her lack of cognitive awareness that you "have to flush the antibiotic out of the IV tubing" is partly because many of us were not taught this vital math / logic in nursing school, or by textbooks, or by Lippincott procedures, or by our own hospital IV policies or by the education dept and preceptors at each new hospital.
    My "Holt 30 CC IV rule" gets most patients a full dose of antibiotics if the bag is 50 CCs, but RNs need to calculate and be more precise (and aware) for larger bags, so Holts second IV rule for calculating the volume to be infused (VTBI) should be used.
    NB: The IV pumps program is not very smart. It is probably programmed to give 50 CCs, so the smart IV pumps make you even more likely to give just under half a dose of antibiotic.
    see RN-IVPB.com and maybe that patient who continues to be febrile 6 hours after his Fortaz with recover faster.
    ...wow, 50% ? That's significant. So you lost me a bit...is your recommendation the nurse set the volume for more?
  9. by   Holt147
    If you want your patient to get a full dose of IVPB anything, you absolutely must program the volume to be infused for at least 30 CCs more than is in the IV bag. This assumes a mere 50 CC antibiotic bag, normal IV tubing and no extensions to patients IV access.
    If the above conditions are not met, go with Holt's IV rule number two, which is:
    Volume in the IV bag
    + 10 percent (the overfill)
    + mainline IV tubing capacity
    + secondary IV tubing capacity
    + any extension tubing or central / PICC line capacity.
    For a 100 CC antibiotic bag, the math is likely to be about:
    100 + 10 + 22 + 9 + 5 = 146 CCs for the volume to be infused.
    Hopefully, readers can work out for themselves how much volume to infuse for a 200 and a 250 CC bag of antibiotics, or venofer or anything else. My books on this subject include "25 to 50 percent of antibiotics do not reach the patient" and "7 IV antibiotic medication mistakes."
    As mentioned in my other post, Lippincott does not tell you haw to give a full dose of antibiotics, nor does any IV policy that I've ever read (except for the ones in my book).
    Sadly, researchers don't even look for this medication mistake. They get hung up on the IV rate, which is actually given to us on the IV bags label.
  10. by   Gaitor
    The different pumps that I have used are per-programed by pharmacy. The problem is that some medications like Vanco seem to always have a substantial amount left in the bag after delivering what the pump is programed for. I don't know if the bags are over filled, the pumps aren't accurate or if the viscosity of the Vano mixture messes up the calibration on the pump drip volume. I never adjust above the set volume or the bag volume(+ additive if liquid like cardizem). I guess how much is left over and add it at the end. I hate getting air in the line.
  11. by   Gaitor
    Great article. My initial thought was that it is a good reminder for nurses like me not to be pressured or rushed when giving medications. My heart goes out to those you wrote about and I can say from experience that it is way better to take ownership of mistakes. It makes it easier to live with yourself afterwards. Fortunately for me no harm was done but I definitely don't have a problem having others verify dosing/rates even just for my peace of mind at times.
  12. by   Holt147
    Fact: The typical overfill is 10 percent, therefore a stated Vanco 250 CC bag tends to be 275 CCs, all of which needs to get into the patient.
    I doubt if pharmacy programs the IV pump. They are almost certainly programmed by the manufacturer, and for that companies stated bag volume.
    Three: If you use a two IV tubing IVPB system, your IV tubing will NOT go dry.
    If you use a one tubing system, you should change the antibiotic bag for a flush bag at the point that the antibiotic bag empties, and program the IV pump to infuse for the total volume of all tubing in use, plus 5 CCs.
    Using Holt's second IV rule for calculating the volume to be infused (that RNs need to program into the pump) check the package that your IV tubing comes in. Your result will be 305 to 315 CCs for a stated 250 CC bag. Leaving medication in the IV bag means that the entire IV tubing is also full of medication, and makes it difficult for our patients to recover, while also putting them at risk for developing MDROs due to half doses of antibiotic being given.
    Look up IV antibiotic mistakes to find web-sites with this info.

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