Why Do We Continue to Harm Patients? - page 2
WAKING UP TO A NIGHTMARE Imagine waking up from surgery in a hospital bed - you can't move, you literally cannot speak, lift a finger or communicate that you are awake in any way. Over the next... Read More
Feb 22OP, two recent threads: "Suicide screening for all is not needed," and "Knaves, Fools, and the Pitfalls of Micromanagement," are worth reading as both discuss patient safety issues, and nurses have made suggestions for improving patient safety.
Improving critical thinking, i.e, "Does my patient with IV fluids running at 125 cc/hr since their procedure several hours ago who is putting out a large volume of urine still need this rate of IV fluids, and shouldn't I contact the doctor to inform them of this and ask if the rate should be reduced since my patient has a cardiac history along with chronic renal failure?" and prioritization of patient needs when providing patient care, i.e. prioritize obtaining physician orders to begin fluid resuscitation and antibiotics to a patient with severe sepsis whose care has already been delayed by several hours over leisurely asking the patient admission risk assessment questions such as "Have you been having thoughts of self-harming?" and "Are you being abused?" are examples. I see too many nurses going on "auto pilot" and not thinking about what they are doing. Measures to reduce systems errors are good, but they don't negate the need for critical thinking and paying close attention to the patient's clinical situation to avoid errors.Last edit by Susie2310 on Feb 22
Feb 23Quote from SafetyNurse1968Technology is helpful, as in the barcode scanner, but technology won't and shouldn't be expected to be able to eliminate all errors by itself. That would be a foolish expectation. The idea that nurses can get by using less critical thinking now there is more technology to assist their practice, for example in administering medications, leads to errors. Errors happen when nurses don't use the five (or how ever many it is now) rights when they administer medications and don't use critical thinking, for example, ensuring that the medication is indicated for the patient's condition and not contraindicated, and when they don't know how the medication works, the expected effect, side effects, adverse reactions and action to take, patient assessment before administration including lab values, necessary patient monitoring, etc.I hear you, and yet I also find it interesting that depending on the study you read, CPOE or barcode admin can cause an increase in error. I think it has to be more than just tech - it has to be a change in culture. Healthcare has to stop blaming individuals and open up to the idea that we are absolutely going to make mistakes - there is no shame in making mistakes. Let's just get that out of the way, admit it, stop firing nurses for doing their jobs, and begin to value the folks who work at the bedside with better hours, higher pay and some respect.
I find your statement "Healthcare has to stop blaming individuals and open up to the idea that we are absolutely going to make mistakes - there is no shame in making mistakes. Let's just get that out of the way, admit it, stop firing nurses for doing their jobs, and begin to value the folks who work at the bedside with better hours, higher pay and some respect." to be rather silly and not aligned with your OP where you are sympathizing with patients who have been injured or killed through medical/nursing errors and with their families, and are calling for action to reduce these errors. I don't think the general public that you are trying to protect would feel quite so relaxed about their being injured or killed through medical/nursing errors and these errors being considered acceptable by health care organizations, to the extent that nurses suffer no employment consequences. You are trying to protect patients, right?Last edit by Susie2310 on Feb 23
Feb 23Quote from JKL33I can't "like" and agree with this more. Here is my experience with "staffing" committees: our unit manager chaired the committee. The same one who kept us lean so she could win brownie points with the brass. For starters, she had to be told she could not have a CNA on the committee to determine nurse staffing. She did have a new grad who previously was a nursing home administrator. Nice person but essentially the manager's cheerleader.Kristi,
This is not directed at you personally, but at the whole "safety" bubble: Some of this is getting exceedingly disingenuous at this point.
I understand why frontline staff must be involved in solutions, and we want to be, but you know as well as I do that the first 30 "holes in the swiss cheese" are things that bedside RNs can't fix, and what's worse, we are very likely to be vilified for caring too much about them or calling any attention whatsoever to them. So then, all of this becomes a bit of a game where we're playing by ourselves.
These nearly 20-yr-old reports and terrible (actually awful) analogies about how many people we're killing have ceased to be useful in this conversation except as attempts to make those with the least power in our organizations suffer with ongoing guilt - while those who shouldn't be able to sleep at night continue to shirk responsibility.
"We" are not sociopaths out killing jet planes full of people.
If you want to help patients (and nurses), the only way is to get real. Nurses and Safety teams have been coming up with mostly asinine (and some good) suggestions the whole time our profession has been being taken over by business people and their hired cheerleaders, who make up whatever facts are needed to suit their cause. And as far as I can see, the "cause" is to appear to be doing something about safety. It's very useful for the public to believe that uncaring, undereducated, poorly-prioritizing RNs and callous, money-hungry jerkwad physicians are the cause of safety issues. Well, we have made a ton of strides and now it is time for others to step up to the plate.
Sorry. I know your work is important but this conversation needs to change in a big way.
What am I going to do about it???? > Spread the word about this damaging, devaluing and demoralizing farce.
We spent the first few meetings developing a vacation request strategy and assorted peripheral issues not related to our daily staffing numbers. One meeting was designated to actually address staffing. But our manager/chairperson dragged her heels on actually scheduling the meeting. When I came to work after a sick day I found she had held it in my absence.
Takeaway: staffing committees and other safety measures look good on paper. It might take a fair bit of sleuthing to see how they are actually implemented.
Feb 24Nurses are understaffed and overworked. They are caring for sicker patients in greater size and numbers with less support, experience, and training. They are supposed to earn subsequent degrees while working full time or more, regardless of future career goals. Additionally, regardless of what the administration claims, at many facilities, there is no such thing as Just Culture. Someone will be made an example of, even for an honest mistake.
It's so sad that the money has shaken safety out over time. As long as bills are paid by the diagnosis instead of the care received and cheap, new nurses are treated as being equal to expensive, experienced nurses, these problems will continue. It's a recipe for disaster, but there are always newer, less-experienced nurses waiting in the wings when it's time to throw out the older nurses. You end up with the blind leading the blind because it takes time and experience to recognize a subtly deteriorating patient. I've heard of nurses hitting the code button and standing there, waiting for a team to arrive, instead of giving CPR, because they are so petrified of doing something wrong.
Feb 25Errors arise from the absolute panic nurses are in trying to get everything done. Often units have no secretary, and there are one to two techs for an entire tele or med-surg floor, and one of them may have to be a sitter....ICU is lucky to have techs, even when taking 2-3 patients, frequently with multiple admissions & transfers, answering phones, dealing with families & visitors, + passing meds, turning and suctioning patients + giving other basic nursing care, and God forbid if you have someone who is trying to circle the drain. Rapids, code blues, outrageous charting requirements, and if you've drawn the short straw, charge duties so you can deal with patient assignments and staffing issues. It's way too much everyday.
Change has to come from the top. All this is upper management squeezing the life out of the supervisors and unit managers to have bare bones staffing, regardless of staff feedback and the negative patient care effects. Somehow, CEO's are going to have to actually start believing that on the ground hands on care makes a difference in patient outcomes, and they are going to have to actually want good care for the patients, at least want it enough that they are willing to pay a little more to get it. As we can see, for now, they are not. We all hear about "patient care is our first priority" at the orientations or occasional pow wows, but we know it's just bs, because if they actually believed "Patients are #1" or whatever, they wouldn't leave one tech and 5 nurses for 30 patients. That's sh*t care and everybody knows it. If one patient goes bad it's a disaster. Pt outcomes and satisfaction suffer terribly because we just need "another set of hands" to help us. No one is lazy; we just want to be enabled to give proper nursing care to all our patients if we bust it for our entire 8 or 12 hour shift.
Anyhow, because of staffing, instead of practicing Nursing Excellence, we are more often than not practicing Seat of Your Pants Nursing, mainly putting out fires and barely keeping the head above the water. That means rush-rush-rush, & by necessity nearly ignoring some patients while dealing with the other needier ones, with very little time for double checking, reassessments, and thinking things through, and hence the perfect storm for errors. Then when someone makes an error that we get dinged for, everyone swoops in so this "never happens again." What happens then? Instead of looking at the root cause and giving the floor more HELP, they add more processes, checklists, and paperwork to an already overwhelmed nursing staff.
Now management is coming back in with that ridiculous and insulting "huddling" crap they had going years ago. Yeah, we are woefully and potentially dangerously understaffed, but we are supposed to just huddle, and if we work together as a team, then we can get through it.... Like it's just us not working as a team or putting our heads together that's the problem. Scripting, huddling...my head is going to explode. A long and meandering answer, but in a nutshell, in looking at error prevention, it's generally all about staffing.Last edit by BedsideNurse on Feb 25 : Reason: paragraphs
Feb 25Another piece of the problem no-one has mentioned yet is that nursing education has changed and the priority in (some?) BSN programs appears to be grooming students for nurse practitioner school. Some nurse educators who participate in this forum have intimated that this is the case. It is not uncommon to read comments on this forum from students who express shock, disappointment, and confusion that they are not receiving the bedside clinical training/experience they had expected and believed they would receive when they signed up for their program, and to hear them say they don't feel prepared to be nurses. I heard this myself from generic BSN students during my ADN-BSN program many years ago. In my observation/experience, health care facilities expect to hire new graduate licensed nurses who have been trained and are able to provide acute care bedside nursing at the beginner level, and many facilities expect new graduate nurses to be able function safely at a beginner level without having to commit a lot of resources beyond orientation to teaching new graduates things the facility believes they should have learned in nursing school.Last edit by Susie2310 on Feb 25
Feb 25Quote from Susie2310Agreed...Nursing programs, especially BSN programs, need a total overhaul.Another piece of the problem no-one has mentioned yet is that nursing education has changed and the priority in (some?) BSN programs appears to be grooming students for nurse practitioner school. Some nurse educators who participate in this forum have intimated that this is the case. It is not uncommon to read comments on this forum from students who express shock, disappointment, and confusion that they are not receiving the bedside clinical training/experience they had expected and believed they would receive when they signed up for their program, and to hear them say they don't feel prepared to be nurses. I heard this myself from generic BSN students during my ADN-BSN program many years ago. In my observation/experience, health care facilities expect to hire new graduate licensed nurses who have been trained and are able to provide acute care bedside nursing at the beginner level, and many facilities expect new graduate nurses to be able function safely at a beginner level without having to commit a lot of resources beyond orientation to teaching new graduates things the facility believes they should have learned in nursing school.
Feb 25As I see it, patient safety (and the lack of) is a multifaceted problem. There are so many components. Health care organizations are often very profitable and have a lot of political leverage. Health care organizations and nursing schools receive public funding. Nursing organizations, nursing schools, and health care organizations have their own agendas, and these organizations are politically powerful and well funded. These are only some of the components. I don't see political change unless enough people become politically active.
Feb 26I am an older Nurse with an ADN degree. I am a safety person first and foremost. Before I give any medication I ask if the patient is or has ever had an allergic reaction to any medication, even over the counter supplements. I have observed some of the younger Nurses I work with constantly rely on the computer to help them with patient histories, allergies, charting, orders and to alert them of a mistake. Trying to go to fast and not taking the time to verify or update patient information can lead to mistakes. Not sure what the solution to mistakes would be, but since medicine is now a business and not about patient's healthcare it will be hard to find out the facts as no facility, hospital or clinic will be willing to cut into there budget to install safety measures to protect patients. I have seen that first hand. Some of us older Nurses are being forced out of Nursing or being required to go back to school. So my option is to retire soon. I keep all my training up to date. I do picc line or any implanted port infusions, apply cast and splints, pulmonary function testing, PRP blood draws, MRT blood draws and many more procedures that I have to stay certified to perform. The young BSN Nurses hired are already doing online classes to further their education to leave which I applaud them. The value of keeping seasoned, experienced Nurses is no longer important in the need to become a magnet organization. By having Nurses do administrative things as well as their own charting, medication administration, taking orders, receiving and discharging patients. A person has only so much time to get things done. With that in mind, mistakes will happen. Having managers come out and help to lighten the load would help. But in most places that will never happen.Last edit by she244 on Feb 26
Mar 3I think there has been plenty of talk, venting, concerns being brought up continuously for at least the past decade and nothing but continues to happen. I live in a right to work state and can honestly say I am tired of it. Poor staffing, non-union, right to work states are the perfect recipe for disaster, high turn overs and poor nursing morale. I am tired of talking and advocating! I have seen no positive change.
Mar 3Quote from Jessy_RNWhat is the alternative? Do you just go to work every day like its a job and hope nothing bad happens? Do you move to another state? What is the ANA chapter in your state like? Are they active? A small donation to the Political Action fund for the ANA or your local ANA would go a long way to making a difference if we all did it. Let's say we all donate $5. Every nurse. That's 3 million nurses. That's 15 million dollars to go towards lobbying. Please don't give up. We need your voice.I think there has been plenty of talk, venting, concerns being brought up continuously for at least the past decade and nothing but continues to happen. I live in a right to work state and can honestly say I am tired of it. Poor staffing, non-union, right to work states are the perfect recipe for disaster, high turn overs and poor nursing morale. I am tired of talking and advocating! I have seen no positive change.
Mar 10The alternative is simple and very in your (my) face. If you want to continue being gainfully employed and feed your family, you just do the best you can with what you have and don't rock the boat. Otherwise, you're going to be labeled a trouble maker and at the end still no change. These days, I just want to go to work, do the best I can, stay safe, keep my patients safe and make sure they're pink when I leave. I disconnect as soon I swipe my badge at the time clock and live my life as normal as possible. That is my alternative. The rest of you have my kuddos, high five in doing whatever it is you do to "make a difference". I am tired, beat and life is too short for misery.
I will cheer you on, on the side lines while staying sane at work.
Quote from SafetyNurse1968What is the alternative? Do you just go to work every day like its a job and hope nothing bad happens? Do you move to another state? What is the ANA chapter in your state like? Are they active? A small donation to the Political Action fund for the ANA or your local ANA would go a long way to making a difference if we all did it. Let's say we all donate $5. Every nurse. That's 3 million nurses. That's 15 million dollars to go towards lobbying. Please don't give up. We need your voice.Last edit by Jessy_RN on Mar 10 : Reason: misspelling
Mar 18To my knowledge, I've not made a med error that resulted in harm to a patient. It's only by the grace of a God because every day it is push, push, push, rush, rush, rush.
We need better staffing. I agree that patients are sicker than ever. They also seem to be needier. Maybe that's because they tend to be older and less able to do for themselves. Maybe they also have expectations of higher levels of service. Maybe it's because, out of fears of liability, we let them do very little for themselves. Then the Powers That Be blame us when patients become deconditioned. We can't seem to win.
It's not just the nurses who are stretched thin. The doctors have been pushed to the limit as well. So are the HUCS, the CNAs, and everybody else involved in patient care. We're all struggling and need to find a way to advocate for each other instead of turning against each other as is too common. I think we're all pretty amazing to accomplish what we do considering how hard we're pushed.
We need better staffing. Period.
We need to communicate better between staff. I spend too much time cleaning up messes that could have been avoided if hospitalists would just talk to specialists, if pharmacists would just talk to physicians, etc.
Everybody is stretched thin so they take shortcuts. Whatever goes wrong, it becomes the nurse's job to fix it. Not enough CNAs? The nurses will just have to cover. The pharmacy tech did not have time to load Pyxis machines on both sides of the floor? That's ok, the nurse can pull from 2 machines for each patient on her med pass. Materials did not have time to stock everything? Well then, the nurse will just have to take time to scavenge or to call every other floor until she gets lucky. Kitchen is out of applesauce for pt to take meds? Get someone to cover your patients while you run to another unit. And so on and so on. We nurses have a lot to do in a limited amount of time. We don't have time to play hunter-gatherer. It adds to our stress levels and is a distraction from patient care.
We need to streamline processes instead of adding meaningless extra steps so that we can appear to be doing something. It should not be all about checking off the right boxes and looking good on paper. Too many falls? Why increase staffing when you can add an extra page of documentation and make it all look nice? Because that extra piece of paper will surely keep Mrs Smith from jumping out of bed and falling while the aid has been pulled off the floor to sit with the CIWA and the nurse is toileting another patient. There are far too many instances where we are documenting in duplicate or triplicate.
And don't get me started about the interruptions! The doctor calls? Drop everything and come to the phone. Ditto with the lab calling with critical values or pharmacy calling about meds. Patient jumping out of bed? Well, there is no CNA available so put those meds you've poured into your pocket and race down the hall to keep the patient from falling. Family members hunting the nurse down because "Mother needs a cup of water" or they want to speak with the doctor Now.
And then the Powers That Be grumble about the lack of critical thinking? We hardly have time to breathe. How many times has a result come back a little bit off and our first thought is " Crap! I don't have time for this! The physician is going give me attitude over this, etc" I really enjoy going over labs and disease processes and putting the pieces together. I like to think I do ok. But I could do better with enough time to think for a minute or two.
I have to agree that all too often we're flying by the seat of our pants. I want to leave at the end of the shift feeling like I did right by my patient. I want to make a difference, even now. Those days are becoming all to rare and it huts my heart to settle for the knowledge that they're just all still alive.
I truly believe that the business school types do not care (because I can't believe that they don't know) how close to the edge we come. I would like to think that if they only knew, they would find a way to make it better. When one of their loved ones is admitted, we're made aware who they are and they're treated well, insulated from the dysfunctional system they've created. I honestly don't know how we reach them when all they care about is the bottom line and their own compensation (including bonuses). All I know is that it makes me wonder how much longer I can work like this.