Errors--system problem or nursing problem?

[dudette10]

For our discussion...

Your patient is scheduled for a thoracentesis. Pt is on Coumadin. Your assessment reveals mild SOB, but you know the thoracentesis and the Lasix you will give are intended to relieve it. Sats are fine on 2L NC, isn't in distress, but you will monitor closely. As you are reviewing meds and labs and notes, you see the specialist wants Coumadin held today, but the internal medicine team did not d/c it off the MAR. You also know the procedure team will want to know the INR before commencing. You see that Coumadin has been given every day, but no INR has been drawn for three days. You call the doc, confirm holding the med and request an INR be drawn. INR comes back 5.4, you report it along with your assessment of SOB and your concern that the procedure will be necessarily cancelled. Pt is stable thruout the day, and you come back on shift two days later and find out the patient went to ICU for respiratory distress. You know all of this might have been prevented with a daily INR and daily dosing of warfarin.

System problem or nursing error?

Pt is symptomatic with severe right-sided heart failure. Nitro-BID is on the MAR, prescribed BID, but the administration guidelines on the MAR state to provide a nitro-free period of 12 hours per day. You review the manufacturer's guidelines which state BID dosing should be six hours apart to allow for the 12-hour daily "vacation". Upon reviewing the MAR, you see the scheduling is 12 hours apart, and the patient has not received a nitro vacation in 96 hours. You call pharmacy to tell them of the problem and provide a suggested schedule that aligns with the manufacturer's recommendation.

System problem or nursing error?

[mariebailey, MSN, RN]

I am new to the floor and hospital nursing in general. My background is in public health nursing. I could kick myself for being naive enough to assume I would be treated as an autonomous professional in acute care, and I'm baffled by the unrealistic expectations thrown on me when I'm running my butt off all day caring for 6 patients. I firmly believe that hospitals would have better patient outcomes if each profession was held accountable for a standard of performance that was clearly defined. Docs, pharmacy, CNAs, RT,etc. included. Nurses can't do everybody's job in 12 hours. I wear many hats: unit secretary, CNA, & housekeeper to name a few, and my plate is FULL. If an INR needs to be ordered and isn't, that should be the doc's problem. If the MAR is incorrect, pharmacy error.

I believe our ultimate goal should be to provide safe, quality care to our patients, but we should be able to rely on other disciplines to do their part. This culture of blaming the nurse...I think it has something to do with the fact that 90% of us are women.

[nurseprnRN, BSN, RN]

I resent the thought that this is a nursing error. Should nursing suggest to the physician very nicely that they screwed up and need to fix it by writing an order to hold the Coumadin and to check an INR? Sure, but it's not OUR error that an INR was not drawn. We don't write orders. Deciding that the patient needs an INR drawn, while obvious, is not in our scope of practice. I say the INR not getting ordered is the fault of the person whose ACTUAL scope of practice involves ordering labs. Just because I catch a physician's error and get it corrected doesn't mean the error is my error.

Wrong, and dangerously so on the face of it. Your scope and standard of practice very specifically burdens you with the obligation to do exactly that, to pick up physician errors and get the prescription for that part of the medical plan of care clarified or amended, in the interest of patient safety. You are required to be that advocate.

[dudette10, MSN, RN]

Wrong, and dangerously so on the face of it. Your scope and standard of practice very specifically burdens you with the obligation to do exactly that, to pick up physician errors and get the prescription for that part of the medical plan of care clarified or amended, in the interest of patient safety. You are required to be that advocate.

GrnTea, I completely understand what you are saying, and I think all nurses should continue to monitor and advocate for the patient in circumstances such as these. I know I will. But, you also know that some environments exist in which the ONLY member of the healthcare team who gets talked to or formally reprimanded is the nurse. Someone else in another thread suggested that we don't know about reprimands to other members of the healthcare team for system errors, so to say that nursing is the only department with hand slaps is a conclusion with lack of evidence. I can easily concede to that point.

Jade, thanks for your contribution. Two points of clarification about the scenarios...this was a paracentesis for pleural effusion, not a thoracentesis for ascites. Also, the administration instructions on the MAR called for a nitro vacation for 12 hours out of every 24. I wasn't changing what the doctor wanted...I was being sure that the scheduling of the dose matched what the administration instructions indicated.

ICUmaggie, good point about 24-hour vasodilation, but, in the case of Nitro-BID (according to the manufacturer's information), applying it for 24 hours may not achieve that goal due to tolerance of the medication if applied continuously.

One last point that I want to make: I will NOT just throw up my hands and say, "It's not my job," but it does get tiresome to have to make corrections day in and day out when other members of the healthcare team aren't paying attention. Something has to give because nursing can't be juggling all the balls and picking up the ones dropped by others.

[icuRNmaggie, BSN, RN]

I was in a management meeting recently in which we reviewed risk management reports. It was an eye opener.

The medical director put his spin on two situations and with great disdain blamed the nurses. Since I was present for both situations, I had to politely correct that misinformation. The room went silent because I refused to play the blame the nurse game. I was and I still am disgusted when I think about this childish and unethical behavior. A nurse can be a fierce advocate, do everything right, save the patient and still be thrown under the bus by weak physicians who don't belong in Critical Care and nursing management who play along.

I used avoid placing blame but no more.

From now on, when I have to fix a physicians error or poor medical management, I will make it crystal clear in my documentation, to anyone who reviews that chart, that the issue was not a systems error, a process error or a nursing error, it was a medical management error. It is self preservation.

[dudette10, MSN, RN]

ICUmaggie, thank you so much for your insight. I have had a 3rd year say to me that a patient was medically mismanaged by the intern/resident triad of internal medicine. I have had the former director of the residency program say to me, "They [residents] are making too many mistakes." I overheard (to my shock) an internal medicine attending say to a patient who was now on acute dialysis, "They almost killed you with too much fluid."

But when it comes down to it, medicine circles the wagons and protects each other. That's not necessarily a good thing, but maybe we need just a little more of that in nursing when clearly it is a system error for which the nurse only had one part.

[dudette10, MSN, RN]

Two points of clarification about the scenarios...this was a paracentesis for pleural effusion, not a thoracentesis for ascites.

Whoops! Thoracentesis for pleural effusion, not a paracentesis for ascites!

[HouTx, BSN, MSN, EdD]

This is a very interesting thread. And it made me realize how fortunate we are. We have a new, highly qualified Chief Clinical Officer(MD) - with an impressive CV focused on improving Patient Safety. He has blown up our 'traditional' methods/processes and is in the process of establishing a much more relevant and effective structure. We now have a Clinical Risk Management department - completely separate from that 'other' RM department - local staff in place at each entity & working with each important function -- even with Informatics!. We have shifted to an HFACS-driven data management system which clearly identifies all those "system" issues.

Our Board has a Patient Safety subcommittee that examines monthly reports. Information (not just data and complaints) is provided back to the direct care staff each month so everyone knows the big picture status as well as any new issues that have arisen. Departments have their own Patient Safety committees - with representatives from all levels of staff. There is a tremendous amount of education going on. Managers are held accountable for incorporating 'Just Culture' principles in to all staff performance issues. Physicians are even being held accountable - yeah, I know!

We're moving from "Who's to Blame".... to "What Went Wrong & How Can We Prevent It From Happening Again?" It's a hugely expensive journey. It's not perfect yet, but we're on the right track.

[psu_213, BSN, RN]

And, specifically regarding the first scenario, I will say that one's not a systems problem - it's a physician problem. If the specialist wants to do a procedure, the internal medicine physician should be aware.

Not to absolve nursing from the problems, but I agree. The specialist should know the pt is on Coumadin. That means that the specialist should write "Hold coumadin. INR in the AM." This would preclude a previous order by Internal medicine. If int. med. comes in after the specialist, he/she should see the hold coumadin order. IF they have questions about it, they should contact the specialist who wrote the order. If they write a "give coumadin" order, then it would be up to the nurse to call that physician and clarify.

It is unlikely that any one error is the result of any one person/entity, but rather many factors, such as physicians, nurses, system, etc.