A sobering story-------

Horseshoe, BSN, RN · Nov 28, 2015

We know she was "talking with a co-worker." We don't know she wasn't arranging for someone to cover a break, doublechecking the other nurse's heparin, answering a question from a new grad, or updating the provider on the baby's condition.

True, but all of those are inappropriate while drawing up an IV med. Not as unprofessional as talking about last night's Dancing With the Stars, but potentially just as lethal.

Anna Flaxis, BSN, RN · Nov 28, 2015

As someone whose family member died as a result of a medical error by their physician, I would definitely think the above scenerio was fair and appropriate. Someone who was habitually careless, flouted procedures or took on a task for which they knew they weren't qualified may be a different story. But someone who made an honest mistake, no matter how serious, should be supported emotionally by their employer, should not face significant career consequences or hardships byond counseling and should return to work in their original -- or a new department -- at their original employer.
People make mistakes. People who make honest mistakes and then immediately set about to mitigate the damage should not be fired, should keep their licenses and should be offered emotional support by their employer.

I agree wholeheartedly with this.

I have not lost a family member, but someone who was very dear to me was overdosed on Dilaudid, because the new grad nurse was used to giving morphine, and gave 10mg of Dilaudid by accident.

My friend felt compassion for the nurse (once she had been Narcanned and was capable of conscious thought), who was tearful and clearly felt tremendous remorse. This was not somebody who acted carelessly- it was an honest mistake. One that any of us could make.

Horseshoe, BSN, RN · Nov 28, 2015

I could forgive a lot, but I could never forgive a nurse causing my child's death by giving her 10 times the normal dose because she was distracted by a conversation and didn't recheck her math. I just could not.

That's not to say that the grief of family members should dictate policy. This is something that probably has to be taken on a case by case basis, and only after careful investigation and thoughtful analysis.

MunoRN, RN · Nov 28, 2015

I could forgive a lot, but I could never forgive a nurse causing my child's death by giving her 10 times the normal dose because she was distracted by a conversation and didn't recheck her math. I just could not.
That's not to say that the grief of family members should dictate policy. This is something that probably has to be taken on a case by case basis, and only after careful investigation and thoughtful analysis.

She's certainly not the first nurse to be distracted while drawing up meds, should all these situations result in a nurse being fired or effectively losing their ability to practice?

It's been reported that the medical examiner's report did not cite the calcium chloride med error as being the cause of death, which brings up an interesting question; should the punishment for the exact same error be primarily dependent on the outcome? Why should two nurses who do the exact same thing be subject to completely different punishments based on how their patients happen to respond to the error?

Horseshoe, BSN, RN · Nov 28, 2015

She's certainly not the first nurse to be distracted while drawing up meds, should all these situations result in a nurse being fired or effectively losing their ability to practice?

Nowhere did I say every nurse who is distracted drawing up a med should be fired or lose their ability to practice. I didn't even say the nurse in question should have been fired or lost her ability to practice.

MunoRN, RN · Nov 28, 2015

Nowhere did I say a nurse who is distracted drawing up a med should be fired or lose their ability to practice.

I realized that wasn't a fair way to put that question, so I added more to my post, you're quicker at responding than I am at adding more info, my bad.

klone, MSN, RN · Nov 29, 2015

But then it got really weird. "Striped of there libidinous and sanity?"

I'm guessing it's a DYAC. Libidinous = license?

Horseshoe, BSN, RN · Nov 29, 2015

I'm guessing it's a DYAC. Libidinous = license?

I think she came on later and said she meant "stripped of their livelihood."

Susie2310 · Nov 29, 2015

I think many people would prefer that nursing errors that result in serious consequences for patients, however the errors arise, be forgiven or dealt with with compassion, and for there to be only mild employment repercussions. That is human nature. Our state Boards of Nursing have a duty to protect the public from incompetent, unsafe, nurses, and to regulate the practice of nursing. As far as I know, the judicial system holds nurses very closely to the standards of competent performance for an RN, to an RN's scope of practice, and to standards of care. We can continue to debate what consequences a nurse should suffer in regard to their employment, and we can continue to debate what is fair/reasonable, but it appears that errors that are serious enough to merit the attention of the Board of Nursing (and yes, I know that not all serious errors are reported), and that are reported to the Board of Nursing, and/or errors that result in legal action being taken against a facility/nurse, often do result in employment consequences for the nurse concerned.

brownbook · Nov 29, 2015

On error management: lessons from aviation,

Letting emotional responses (what if this were my loved one) be our guide on what to do is wrong. I'm not good at Internet/Google, computer stuff. You the above headline I pasted from an article on dealing with errors.

Aviation experts, NTSA, break down every airplane accident into minute details to find out what went wrong. And WITHOUT PLACING ANY BLAME (of course there are times it really is one idiots fault) makes a plan on what steps to take to avoid a repeat. Has anyone noticed that there are few, if any, airliner crashes anymore?

Nursing, medicine, surgery, has to do the same. WITHOUT BLAMING ANYONE PERSON, break down what went wrong and then take steps so it is not repeated. Whoever makes a mistake must be allowed to report the incident without fear of punishment. Otherwise (DUH) many simply will not report a med or any other error they made.

CountryMomma, ASN, RN · Nov 29, 2015

That first article was rubbish. The second article was much more readable.

I'm indecisive. I do feel that a medication error of that magnitude deserves a corresponding consequence. Any time a medical professional is mixing IV electrolytes, there should be complete concentration on the task at hand, imho. So what if it was a coworker chatting about little Bobbie's football game or the manager ragging about a negative PG response. The nurse in question should have been capable of saying hold that thought, I'm in the middle of something critical.

That being said, I struggle with also agreeing in part with the idea that punitive med error cultures create more errors because of human nature to avoid criticism/shame/harm to self.

There's a fine line somewhere, but I am hugely uncomfortable trying to define it.

As an aside, I'd like to share a story about a class of student nurses, and where the "I don't want to lose my license!!" theme comes from. Once a upon a time, a class of 40 (or so) student nurses, all just a month from graduation, come together for a day of presenting their QI and PICOT topics. It was generally a relaxed affair, and the students were feeling hopeful and even, dare they say, slightly confident that they could actually be a nurse.

During the lunch break, their instructors had them watch a video on the Josie King (?) story, and then one on a nurse (julie thao) that had confused an epidural w an antibiotic.

Those student nurses were shocked, dismayed, and terrified. No one told them this was extreme. No one said it was uncommon.

I still remember, vividly, turning to a good friend after the videos were complete, and whispering "I think I can't do this. If I mess up, I'm going to jail."

Not one teacher corrected that belief.

cindy_rn456 · Nov 29, 2015

I've been a licensed RN for over 20 years.

Then you must work in a utopia