learning from mistakes...too many?

[miss.bandaid]

I have been an RN for 3yrs now. I believe it is unreasonable to be perfect, yet I am incredibly hard on myself for any mistakes I have ever made! I always reassure my co-workers that a mistake is a learning experience, but when it comes to myself I just can't accept that! I remember as a new grad taking short cuts like only swabbing a central line port for 30 secs vs 60 secs just because someone said it was not a big deal(but this was not our policy). Or missing an important med because the staff making the MAR forgot to write the time the med was due. Or holding an NG feed for a few hours until the doc was contacted because the pH was too high during placement check(the doc was soooo mad that the feed was paused!). Or not being caring enough at times when a shift is hectic/busy. And one time I forgot to swab a buretrol before putting a med into a central line. I almost died, but was too new and stunned to think about changing the line, so I just ran the med(charge nurse didn't give any direction at the time either). Are these types of mistakes huge? In my mind they are. Why can't I let them go and chalk it up to learning like I preach to so many others. Is it "normal" for nurses to make some poor choices as they develop in their careers. Do other people make mistakes(no need to be specific) and harbor low self worth/esteem. I find nursing to be such a HUGE responsibility, people are trusting us with their lives...so much pressure to be flawless! I am told by my co-workers that I am an excellent nurse and a great teamworker(I'm the unit support gal), but I don't feel it. I can help others, but not myself in this circumstance! Can anyone reassure me that I am progressing as expected, or does it sound like I need more fine tuning? Sorry so long!

[KacyLynnRN]

You sound a lot like me...I have been a nurse for 2 1/2 years and I have made some mistakes and I did beat myself up (ruthlessly!) about them...but I am trying to change my attitude. I keep telling myself, NOBODY'S perfect...and if a co-worker who had been a nurse for any good length of time would tell me they had never made a mistake, I would be scared...because I don't see how it's possible...

If it helps you out..I am in the same boat. We need to keep beating ourselves up over stuff and cherish ourselves, especially for choosing to work in a profession that is so difficult and requires you to give so much of yourself.

Just repeat....NOBODY IS PERFECT!!!!

:) Kacy

[KRVRN, BSN, RN]

So if I make a med error I shouldn't feel bad... I should just blame management. That sounds easy.

[Bill Levinson]

so if i make a med error i shouldn't feel bad... i should just blame management. that sounds easy.

no, that is not how a quality management system works. if you make a med error you shouldn't feel bad but "blame management" is not the answer. the idea is not to blame people but to fix the problem permanently. you must identify the reason the error occured and the system in which you work (procedures, equipment, software, and so on) must be changed so no one can possibly make the same mistake again. if you look at the preceding example from nurstudnt546, you will find that other nurses made the same mistake, and for the same reason: the computer system presented them with information that could easily be misinterpreted.

as an example, suppose the pharmacist dispenses the wrong medication or dose because he couldn't read the doctor's handwriting (a problem that is reputed to kill 25,000 people a year, by the way). the solution is not to blame himself or the doctor for that matter, but rather a system that allows handwritten prescription. a possible change is to require the doctors to enter prescriptions on palm pilots or the equivalent (which also would allow a computer to check for unusual dosages and interactions with the patient's other prescriptions), which would of course take care of the handwriting problem. this would make it impossible for the mistake in question to ever happen again. see for example http://qhc.bmjjournals.com/cgi/content/full/11/3/261

my position as a quality engineer is that any medical error or near-miss (i.e. you were about to give the patient the wrong medication but caught the error in time) should initiate a corrective action request or quality action request. this requires that the organization in which you work:

(1) identify the problem (the mistake or near-miss)

(2) identify the problem's root cause (why it happened).

(3) identify a permanent correction

(4) implement the correction, e.g. by changing work instructions, equipment, and so on. this is known as standardization.

(5) identify all other activities that could benefit from the improvement. this is known as best practice deployment.

[KRVRN, BSN, RN]

It would be nice if we could prevent errors from happening simply because we have identified it as possible. Just not possible, though. So many things come into play when a nurse makes an error.

[Bill Levinson]

Here is an example of how an equipment change prevents "mistakes" that can endanger patients (or medical staff). I recall having blood drawn during blood drives with lancets that the nurse then discarded into a special container. The problem with these lancets, of course, is that the nurse might accidentally prick herself with the bare needle before disposing of it.

This is extremely unlikely but, if the nurse performs this task five thousand times a year, you can see how the chances add up. Fortunately most people who donate blood are not HIV-positive (at least that they know of) but the chance of an accidental needle stick is still undesirable.

So someone developed a lancet that, when it is pressed against the donor's finger, makes the stick and then immediately retracts into a plastic sheath, thus covering the needle instantly and making it impossible to stick anyone by accident.

This exemplifies Henry Ford's job design principle: "Can't" rather than "Don't." Instead of posting a sign that says, "Don't monkey with the buzz saw" (a proverb that was said to be quite common among many four-fingered men), you put a guard on the machine so the worker can't put his hand into the buzz saw. Another example is a press that requires the operator to press two buttons, spaced well apart, to operate. They are positioned so the operator cannot possibly have any part of his body in the press when it closes.

The lancet I described follows exactly the same principle, which can doubtlessly be applied to many other medical activities.

[nurstudnt546, BSN, RN]

Bill, I like your thinking and wished you worked at my hospital. :)

[OhNurseLisa]

in reading your post, bill, i had to laugh as i remembered a t-shirt i saw recently. it said, "just when you think something has been made completely idiot-proof, they'll come up with a smarter idiot". now, i'm not in any way suggesting anyone on here is an idiot, so please don't take it that way. what i'm saying is that i agree totally with bill's assessment of what needs to be done.

i imagine most of us would think a sign telling you not to "monkey with the buzz saw" would be more than enough to get the point across. i'd like to think we all would be aware of that without being reminded. but, i bet most if not all of us have also known people who think the rules are made for everyone else except them. so, they eventually "monkey with the buzz saw" one too many times and then have to pay the consequences. when the guard is added to the saw, it is now almost virtually impossible to disregard the rules of safe usage.

in a perfect world, signs would be read and obeyed, instructions would be followed, and all procedures would be done just as the policy says they should be done. but, as we've learned, there isn't any such place and the sooner we all accept this, the better off we all are. the guard on the saw, the lancet that retracts, and the iv pumps that automatically clamp the tubing when it's removed from the pump are all examples of what can result from this acceptance. i'm pretty much convinced that if there is any possible way something can be used incorrectly, misinterpreted, or "fixed so it'll work better", someone, somewhere will figure out how.

i know we all have the best intentions and want only the best for our patients. i know from experience how awful that sinking feeling in your stomach is when you realize you just made a med error. for so long, we've been afraid to admit our mistakes for fear of being sued or fired. as a result, the same mistakes are repeated over and over in silence and we miss the opportunity to see we're not alone in our imperfection. we lose our chance to spare someone else the heartache and grief that comes from our errors. (i am in no way saying we should not take responsibility for our mistakes. we just need to do this without having the "finger of blame" pointed at us.)

i think bill definitely has the right approach to this widespread problem and i hope that the upper-level management of all medical facilities can be convinced that not only will this make things safer for our patients, but will also save money in the long run. (how could any hospital administrator not be interested with benefits like that??)

i'd like to read more about the iso-9000 system of quality management, especially how it can be adapted to health care. are there any specific websites you recommend or should i just do a google search? thanks!

[Bill Levinson]

i'd like to read more about the iso-9000 system of quality management, especially how it can be adapted to health care. are there any specific websites you recommend or should i just do a google search? thanks!

try http://qualitypress.asq.org/perl/catalog.cgi?item=h0987, "iso 9000 at the front line." (i do not have a commercial interest in this book, by the way, as i wrote it for my former employer, which gets all the royalties.) it shows how iso 9000 helps reduce errors and improve quality in industry. http://qualitypress.asq.org/perl/catalog.cgi?item=t300 is the actual international workshop agreement that applies iso 9000 to health care.

it sounds like you understand exactly how iso 9000 is supposed to work! :)

[apaisRN, RN, CRNA]

Our Pyxis system changed so that it no longer asks you how much med you are giving - instead it "assumes" you are taking the lowest ordered dose and you have to override it. Example: Pt is ordered Percocet 1-2 tabs q4 PRN. I tell the machine I want Percs and it says I'm taking 1, and if I'm not on the ball I take two from the drawer and create a discrepancy. Happens to me personally a couple times a month, so must happen daily in the dept overall.

Also, I noticed recently that if an omeprazole syringe by NG is ordered QD, it is ordered for 0700, meaning the night nurse gives it. If it is ordered for BID, it is timed for 0800 and 2100, meaning the day nurse gives the first dose. I saw omeprazole on the med list, found it in the fridge, and gave it with 0800 meds to a patient who had already had it at 0700. I should have double checked, I know, but I'm so used to giving it with my AM meds. A large proportion of our vented patients receive it. I didn't cause any great harm but it struck me when it happened as a system ripe for an error.

[NurseFirst]

Try http://qualitypress.asq.org/perl/catalog.cgi?item=H0987, "ISO 9000 at the Front Line." (I do not have a commercial interest in this book, by the way, as I wrote it for my former employer, which gets all the royalties.) It shows how ISO 9000 helps reduce errors and improve quality in industry. http://qualitypress.asq.org/perl/catalog.cgi?item=T300 is the actual International Workshop Agreement that applies ISO 9000 to health care.

It sounds like you understand exactly how ISO 9000 is supposed to work! :)

I've known about ISO 9000, used to work as a SQA Engineer. Went from there to working in Release Engineering. Satisfied my need to get things "exactly right." (I can be a bit obsessive.) It was great: if I found something that I wanted to make sure wouldn't break--I would just write shell scripting to make sure it couldn't be done. I had a wonderful co-worker who would make simple mistakes frequently, but they were mistakes that I could write scripts to prevent; she was a great worker otherwise. It drives me a bit nuts in clinical to see ALL the things that can go wrong, yet nurses are expected to get it ALL right (and there are no scripts that I can write!) (Hmmm....I'm beginning to think I see a future in nurse informatics ... :)

JCAHO has made a small move in trying to correct med mistakes, such as preventing certain abbreviations (qd; u; and more--I saw a chart the other day which listed "the dirty dozen" which were 12 common med abbreviations that JCAHO institutes are no longer supposed to use.) And, I guess, there are certain kinds of med names that get confused (cerebyx, cerebrex, celexa)--and for which reason the author of my pharm text thinks that we should go to using generic names only (fat chance!). And I'm not so sure that phonetic ambiguity would be cured this way--there may be even more ways for it to go wrong...

One of the VERY interesting medical term ambiguities I realized the other day when our instructor was discussing Fluids and Electrolytes: hypokalemia is low blood potassium. However, hypocalcemia is low blood calcium. Our instructor actually said hypo (or hyper) kalemia when she meant hypercalcemia. And for that matter---hypo and hyper sound too close as well!

By the way--a very simple fix (at least a start) on the new computerized med system would be to put the 5 "rights" in a different color. Or, a prefix:

medication on hand: whateverdrug 2 mg/tab

medication rx: 1 mg every 4 hours

dose to deliver: 0.5 tab (=1 mg).

I'm not sure that I think trying to get doses in "whole pills" is a battle worth fighting, however. First of all, I don't think that's where the majority of errors are made (but have no research to back it up, of course). If we can't get 0.5 pills correct-who would trust us to draw up any meds in syringes, which have far more variety than 1 pill or 1/2 pill?

(Speaking of which, one of the DUMBEST, most error prone things I've ever seen is "combining insulins." [bill--this is where the nurse combines a certain number of units of "long lasting insulin(NPH)", usually a standard dose; with a number of units of "short acting insulin(Reg)", usually based on a "sliding scale" depending upon the blood sugar--into 1 syringe. You have to do it in the right order -- which is draw up the Reg insulin first, then draw up the NPH insulin in the SAME SYRINGE with the Reg insulin already in it, after first having put air into the med bottles in the opposite order--and not contaminating the NPH with the Regular--trickier when you consider that you have to get all the bubbles out...])

Interesting topic...very interesting...

Where can I read more? (for free...I'm still a student...:) Is AQS the only organization which has a group looking into this?

NurseFirst