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   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.
  9. 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.
  10. by   Haddoa
    I made an error where there was no harm to the pt, it was still a significant error to me. I felt I had no one to talk to, no where to turn. I ended up seeing a therapist and with in a year leaving bedside nursing all together as the ptsd and trauma from being the 2nd victim is such a real thing.
  11. by   DaveAlphaRN
    I agree that overly complicated safety systems make failure more likely. From a quality and safety stand point; simplifying work processes is considered a strong action plan by TJC. We want to promote a just culture and in a just culture we understand that people will make mistakes and we want people to own them. Nobody goes to work planning to make a mistake let alone harm a patient.
  12. by   Nurse Beth
    Quote from Haddoa
    I made an error where there was no harm to the pt, it was still a significant error to me. I felt I had no one to talk to, no where to turn. I ended up seeing a therapist and with in a year leaving bedside nursing all together as the ptsd and trauma from being the 2nd victim is such a real thing.
    I'm so sorry. It's really under recognized - the second victim and trauma

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