Quote from Boog'sRN246
On my floor, med errors aren't handled punitively. We aren't written up or disciplined per se. Med errors are always handled as learning opportunities...unless someone tries to cover up the error. When something carries the potential for punishment, it's surprising what people will do in order to avoid being punished.
It's pretty sad that it was 1999 when IOM report "To Err is Human" came out. Let me quote a paragraph here:
Why Do Errors Happen?
The common initial reaction when is to find and blame an error occurs someone. However, even apparently single events or errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur. Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer.
It has been over a decade, and yet punitive actions are still rampant especially in LTC.
Did this new nurse receive adequate orientation? Was she under pressure to rush (very likely since she was already late)? Was it a busy day and she was fatigued?
Errors should not happen but nurses are human. We face so many environmental, systemic barriers. Sadly, still too many people want to punish the nurse instead of helping the nurse to avoid error in the future by improving the system.