Medical Errors that slide and Nursing retaliation

[ArrowRN, BSN, RN]

How does one deal with a medical error a nurse does that you as an RN witnessed. I saw a nurse using 1/2 NS during a blood transfusion instead of regular 0.9 NS. My preceptor was there and she did not intervene for the patient. Later she called me to give advice and told me that was very wrong and I said, yea I noticed the error but aren't you going to tell the nurse who made the mistake anything or report the error? No she said, she does not want to be a snitch.

I'm only few weeks into nursing, but I felt that what should have been done is the infusion stopped and have the error corrected at that time. Nothing happened to the patient but its rather obvious nurses have a deep fear of retaliation. Why is this and how can we begin to change the atmosphere so we can all learn without fear of loosing out jobs? This one who made the error has been here over a year and if I'm now out of school and I see that error, it makes me wonder what else she did , that no one is teaching her or correcting her.

What is done at your institution if a mistake occurs? What would you do in the above?

[RN403, BSN, RN]

Mistakes happen. When they are recognized they should be addressed. I would hav just alerted the nurse so that the correct fluids could be hung. Maybe she just didn't realize. It happens.

[KelRN215, BSN, RN]

"Suzy, did you notice that you have 1/2 Normal Saline running with this blood?"

How did you come to witness this?

[HouTx, BSN, MSN, EdD]

You're right - and this is characteristic of a culture of fear.

The alternative is to foster a culture that TRULY emphasizes patient safety - including rewarding and acknowledging anyone who makes a positive contribution, even if it is catching a 'near miss'. Staff understand the big picture - which means they realize that ALL errors need to be reported because this data is essential for systemic improvements.

[edimo]

The alternative is to foster a culture that TRULY emphasizes patient safety - including rewarding and acknowledging anyone who makes a positive contribution, even if it is catching a 'near miss'. Staff understand the big picture - which means they realize that ALL errors need to be reported because this data is essential for systemic improvements.

This is true at my workplace. When the higher ups started posted boards on the units with the incidents of "near misses" on the units, we (nurses) gave them feedback. Why? Because patients and families would stop and be like "what's that supposed to mean?!" and you started to have this culture of fear and non-accountability. So we changed the wording around to reflect a more positive tone and one that encourages people to report incidents and near misses and it actually worked. Now patients and families are aware that we're on "the look out" (so to speak) and they feel safer.

As for the nurse that hung the wrong fluids, I would have just pointed it out to her.

[Gooselady, BSN, RN]

This is a 'red flag' in my opinion. It tells you a lot more about the general culture of this unit than you may think. Another person mentioned a culture of fear, and I agree.

This nurse put the patient's safety a lower priority than 'keeping the peace'. Major red flag. Keep your butt covered, do your job to your best personal standards (as you would anywhere) but here, there may be challenges to just doing that. Let's hope not, but sadly, part of nursing is recognizing when a unit or hospital is 'sick', a few of them are. Your professional license and integrity are your top priorities, not keeping people from retaliating against you. See how it goes, and if it starts looking worse don't feel badly about transferring out. Life is too short and too much can go wrong even when you are doing your darndest best. I've worked in both kinds of environments. I think I could do any kind of nursing as long as the general culture is 'well', supportive and people are encouraged to LEARN from mistakes rather than hang their head in shame.

Last year, a friend at work MY age found herself pregnant (SURPRISE!). I followed her one shift where she hung the first of two PRBCs. As we did bedside report, I saw all these discrete 'bubbles' of blood in the line, spaced apart in the IV solution. I looked up and eek, she'd hung blood with D5NS! The line LOOKED like it were full of clots! Even better, it was a central line.

It was shocking, and she felt horrible, but we teased her for having pregnancy brain syndrome and the rest of us took to heart how easy it is, when in a hurry, to grab what LOOKS like one thing and turns out to be another. Plus she didn't scan the bag, so a few lessons learned.

This is the kind of environment you want to find a job in. You learn so much more, and the patients get much better care for it. There's NO need for such fear and punitive actions. If a particular RN is continually making mistakes (we had one of those too), she needs 'help'. This one needed to not do acute care . . . but no one gossiped about her much, just kept reporting the errors we found to the manager. A few even pulled her aside in a 'nice' way. Turns out her home life was upside down and she was older, and admitted she was horrified by her mistakes and maybe needed a different setting to work in.

[ArrowRN, BSN, RN]

"Suzy, did you notice that you have 1/2 Normal Saline running with this blood?"

How did you come to witness this?

This was during handover at shift change, we go in the pt rooms to give report and i saw it. As last poster noted about scanning the bag, the computer should have flagged it at least, I would think

[KelRN215, BSN, RN]

This was during handover at shift change, we go in the pt rooms to give report and i saw it. As last poster noted about scanning the bag, the computer should have flagged it at least, I would think

When I worked in the hospital, scanning wouldn't have flagged anything in this scenario because normal saline wasn't ordered with the blood, it was just standard of care that a saline bag was set up with the blood. If you scanned it, you'd get a warning saying "0.9% Normal Saline is not ordered for John Doe." Maybe if the nurse had tried to scan, she would have noticed that it told her she didn't have an order for 0.45% Normal Saline and realized what she was about to hang, or maybe not.

Regardless, it is not "being a snitch" to address the error. It's not easy to confront your colleagues about something they missed either, though, but patient safety has to come first. I once took a patient from a new nurse who was on double IV antibiotics due to cellulitis. When looking at his meds for my shift, I noticed that Vanco (which was ordered q 8hr) was not timed until 11P that night and hadn't been given since the dose the child received in clinic prior to being admitted. This was a big deal and had to be addressed. Partly it was a systems error- the med was ordered with first dose "stat" (this often had to be done to light a fire under the pharmacy's behind to make the medication and get it delivered) so the pharmacy timed it, for, let's say 4P when he was admitted to the floor. But the patient had just received a dose in the clinic so it wasn't due at 4P. The computer then automatically timed the next dose for midnight (8 hrs after 4P) and when the day nurse charted "not done" on the 4P dose and rescheduled the next dose, she meant to reschedule it to 11P but since the current dose was midnight, it had tomorrow's date and the computer rescheduled the next dose for 11P tomorrow night, over 24 hrs since the last dose was given, even though the order was q 8hr. There was no safety net in the computer to prevent this from happening and it was an oversight on the part of the nurse who did it. The night nurse (who was a new grad recently off orientation) didn't notice the error and didn't give the child any Vanco overnight, so by the time I came on, realized it and dosed him, 17 hours had passed between doses. I didn't want her to think I was throwing her under the bus, but the error had to be addressed so I asked her about it in report and then filed an incident report as required by policy. Nothing bad happened- the educator simply met with the new nurse to discuss the situation. Incident reports/addressing errors are not meant to be punitive, issues can't be fixed if they are not addressed.

[Gooselady, BSN, RN]

TO KelRN; same for us. We didn't have NS 250ml ordered with the blood, so we put it in as a 'standing' verbal order with blood transfusion orders. As automatic as our EPIC was, it wasn't perfect, we still had to manually enter things and this was one of the more important ones, or else we see issues like the OP.

And yes we LEARNED fast to thoroughly check admission orders because antibiotics were frequently timed wrong, ordered (in error) as a one time dose, or you'd get two Vanco admins within two hours.

[ArrowRN, BSN, RN]

KelRN215 thats good info to know, as a new grad myself I did not know the computers can mis-time meds so its something I will look out for. I'm sorta stuck in the "getting tasks done" stage as most newbie are required to get up to speed and this is where we can make a lot of errors.