Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

On 1/24/2019 at 11:29 PM, Susie2310 said:

In my opinion, one of the problems is that nursing education today consists of much less hands on practice at the bedside taking care of patients than in the past, and practicing skills in Sim lab for 10 weeks (as you mentioned in your article) and then going to the facility to "observe" staff providing care instead of actually providing hands on patient care under one's clinical instructor's supervision means that students are far less prepared to practice than in the past.  When I was a student we learned/performed the skills in the skills lab, were checked off for competency, and then performed the skills on patients we were assigned to in the hospital under our clinical instructor's supervision.

You seem to be contradicting yourself when on one hand you say that medication administration is far too complex for individual nurses to be held responsible for medication errors (when they administered the medication) the majority of the time, yet on the other hand you reference your students' training (10 weeks in Sim lab and then at the facility to "observe" the staff providing care) while stating that BSN trained nurses have been shown to have superior patient outcomes - what particular outcomes are you talking about?  Your comments lead me to presume you are not talking about safe medication administration outcomes. 

The five/six rights are not obsolete and are still referenced in nursing procedure books (I have a current edition of a reputable one) for medication administration.  The five rights work to prevent errors, and do prevent errors, but more knowledge of medications and of health care processes is necessary in order to administer medications safely.  Vigilance and critical thinking are necessary also; one cannot just go on autopilot.  You said the five rights only works when we do it.  Well, of course, and the recent thread about the Vecuronium error contains many references to safely administering medications and using the five rights; did you read that thread?  A number of nurses who posted on that thread made the point that the nurse is the last defense before a medication error reaches the patient, and therefore needs to have a personal practice with a robust method for preventing medication errors, including the five rights.  Nurses are held individually accountable for their practice by the state Boards of Nursing.   

 

Thank you so much for reading and commenting. I agree that hands on practice is a severe limitation for nursing students these days. It is becoming more and more difficult to find facilities who will allow students to come and learn how to be nurses. Even when we can find facilities, students are often very limited in what they are allowed to do. Many places don't allow students to even pass medications any longer. 

The point I am trying to make in the article is that though nurses are ultimately responsible for patient safety - you are so correct - we are the last line of defense, medication administration is complex and that considering other options and ideas for supporting safety is important. 

Outcomes that are improved by having BSNs and MSNs are the bedside include decreased patient mortality (which may or may not be caused by med error - that statistic is not available), decreased hospital stay, and reduced readmission rates. 

I agree that we must be held accountable, I also think that institutions pass the buck to nurses. It's a fine line, and a tough one to balance. I am advocating for nurses to understand that admitting to error is the first step towards preventing it in the future, and that we shouldn't be penalized for admitting that we have made mistakes.

On 1/25/2019 at 2:52 PM, Miss.LeoRN said:

Sometimes I feel like the persons who write these "checklists" never have actually worked on a floor. What is the rationale behind a head to toe prior to giving medication? I can't imagine having to head to toe my patients any time I give them their medications. Or taking their vitals that many times, unless the particular med I am calling for needs current vitals and they hadn't already been taken in the past 15 minutes. It's bad enough that when I started my patients' all looked at me as if I were stupid and like I was an idiot every time I went to give them meds and I was asking them "name and date of birth" for the 6th time..  

I completely agree - and as a new instructor I have to be very careful how much I criticize the status quo. It is my passion to move nursing education forward so that what we teach students is more closely related to reality. I also think the culture of nursing gets us into bad habits. I hate that there are seasoned nurses who make newer nurses feel "dumb" for doing the right thing (not to mention patients doing it as well - I never even thought of that!). I try to warn my students ahead of time that this may happen, but it's so frustrating. I really appreciate your comment.

On 1/26/2019 at 6:23 PM, JKL33 said:

It would help if it were clarified that, as I recall, the poll in question did not ask if one had ever made an error, it asked if one had ever made  error that harmed a patient. Implicit but not stated would be the idea that one would need to be aware of harm caused in order to answer the question in the affirmative. 

Sure, everyone could have answered "not sure" - but I am guessing people answered based on whether or not they are aware of having made an error that  caused harm to a patient. Since that's what the question asked.

Good data reported in a genuine manner is important.

Thank you so much for pointing out my mistake. 

On 1/26/2019 at 6:27 PM, morelostthanfound said:

Absolutely-this .  54% of nurses having never made an error?  That is an absolute statistical impossibility-sorry!  Having worked in direct care for many years and administered thousands of medications (as most acute care nurses do)-regardless of one's cautiousness or attention to detail, a med error, unfortunately, is an eventuality.  Also don't get me started on the recommendation to join the ANA to promote patient safety.  The ANA's last position statement on nurse/patient ratios made it abundantly clear to me that they were in bed with large healthcare associations who are fighting tooth and nail this very important safety measure.  

I erroneously reported that 54% of nurses who responded to my article stated they had never made an error - but I should have said they stated they had never made an error that harmed a patient. 

Do you have any solutions for how to promote patient safety other than joining the ANA? 

I should have posted this in the article - evidence for improved patient outcomes when cared for by a BSN:

"hospitals in Pennsylvania had “a substantial survival advantage” if they were treated in hospitals with higher proportions of BSN-prepared nurses. That groundbreaking study, published in the Journal of the American Medical Association, found that a 10-percent increase in the number BSN-prepared nurses reduced the likelihood of patient death by 5 percent.

The link between nurse education and patient outcomes was confirmed in 2011, when Aiken published a study in Medical Care that found that a 10 percent increase in the proportion of BSN-prepared nurses reduced the risk of death by 5 percent. In 2013, Aiken co-authored a study in Health Affairs that found that hospitals that hired more BSN-prepared nurses between 1999 and 2006 experienced greater declines in mortality than hospitals that did not add more BSN-prepared nurses. “We’ve established this association over and over again,” she said. “If hospitals really want to improve care, they should hire more nurses with bachelor’s degrees.”

https://www.rwjf.org/en/library/articles-and-news/2014/04/building-the-case-for-more-highly-educated-nurses.html

8 minutes ago, SafetyNurse1968 said:

Thank you so much for pointing out my mistake. 

 

On 1/26/2019 at 7:40 PM, mtnNurse. said:

Susie, I think you are missing the point of why some places give nurses a way to report mistakes with no threat of penalty. As you said yourself, if there's a possible penalty, mistakes will often go unreported. On the other hand, if there's no possible penalty, we can learn from the mistakes made and investigate the root causes. We are better able to find ways to prevent future mistakes if more mistakes are reported which will happen if there is no threat of penalty.

Penalizing nurses for errors will not reduce errors. Understaffing, a very common problem, will cause mistakes (this seems like such common sense to me that it baffles me when people wonder why mistakes are made) -- a nurse will have much less time to ensure safety when assigned too many patients. Also, as people have pointed out, nurses are humans and humans make mistakes. No matter whether nurses are held more accountable as you wish, mistakes will be made for these reasons at least. If every nurse who has ever made a mistake was removed from their job as you may wish, there would be even fewer staff causing even more hazardous conditions to care for your loved one.

I agree with you that the public has a right to competent, safe care. But if you want to hold someone accountable, do so with whoever is deciding to give the nurses (or doctors or others) more patients than they can safely take care of. What is your solution? If we fire everyone as soon as they make a mistake, will that cause hospitals to suddenly decide to hire enough staff so that mistakes are more easily avoided? 

There is no hospital, nowhere, that reporting an error causes a penalty for the nurse reporting it.  In fact, the Joint Commission Requires it.  

2 hours ago, Jory said:

There is no hospital, nowhere, that reporting an error causes a penalty for the nurse reporting it.  In fact, the Joint Commission Requires it.  

We see stories here all of the time from nurses who were fired for medication errors, and I'm not talking about errors that killed a patient.  Anecdotes, I understand.

7 hours ago, Jory said:

There is no hospital, nowhere, that reporting an error causes a penalty for the nurse reporting it.  In fact, the Joint Commission Requires it.  

That thinking is just a little naïve, it happens all the time.