quality improvement?

[beannie]

Hi all. I am in the middle of an internal/external what you want to call it conflict. The other day I wrote a QCC on a nurse who is new but has 8 yrs experience. The problem was that there was an antibiotic that got missed on her shift, the even bigger problem was that the patient was admitted the day before and antibiotic therapy was not initiated on that date, so for 24 hours the patient did not start her antibiotic therapy. If we were trying to beat sepsis it was a pretty poor attempt. So I told that I wrote the QCC b/c I would want to know if it were me. I felt awful telling her this. Her reaction - she started crying and said that did not enjoy working here and that she felt it was an unsafe environment. Again, I had a very guilty feeling. The problem is that there is some merit to her statement. Nurses are constantly being called away to help with toileting, turning, etc... What do you do, risk a fall to prevent a med error? I have been on this unit for a while and have learned the ropes, but the risk of error is still present. So, my external plight is what to do about this. I hate writing QCC's!!!

So here is what I would like to hear about,

1) QCCs are the only way to track and report errors. If there is no documentation stating errors are or have occured there is no one who acknowledge such, i.e administration. If changes are to occur, then there has to be documentation that a problem exists. Most errors stem from a systamatic fault/root cause. Most of the nurses on my unit say they have never written a QCC, they instead go to the person to let them of the mistake. If these errors go undocumented, how will patient safety improve? Are we not putting patients at risk by not documenting? Errors are under-reported because it makes individuals feel vulnerable. When staffing is poor, supplies low, etc.. there will ultimately be consequences. Are we not responsible as a whole if we don't take accountability not only on a personal basis but should that not fall on the heels of our supervisors and administrators as well?

2) Md's don't "tattletale" on each other, and why in nursing is it seen as a "tattletale" scenerio?

3) If morale is low then patient safety will be compromised. Should we then not report errors? Is there not another way other than to blame individuals? Our hospital has anonymous reporting, but ultimately the individual is approached and it becomes the individual who is at fault. I believe in accountability, but if errors are under-reported then there will not be improvement for all nurses.

Does anyone have a system that works in their hospital?. I feel like I never want to write another QCC again!!!!!. But what will happen if Quality Improvement has no reports of errors, will they not have evidence that shows nursing is need of quality improvement??

I am at my wits end on this. In my opinion, errors should be reported, not under-reported. I feel nurses should not feel it reflects upon them, but rather upon the system or environment. Sure some nurses are not competent, but the majority are. If the majority feel they are unable to provide a safe environment and have poor job satisfaction, then there has to be accountability within the system. Not just a continuation of grumbling that goes un documented. How can this be done without compromising the integrity of nurses or the morale of the unit?

[TazziRN, RN]

We (at our facility) don't see QCC's as punitive, but as learning tools. Being written up and having a QCC written up are two different things. One is punitive, the other is to try and prevent the problem from happening again. You did the right thing.

[dekatn]

You did the right thing. I think we are all in a catch 22. When I am standing at a med cart pulling up meds and a call light goes off, somebody yells,"I need help", somebody is falling or about to, my first instinct is to drop what I am doing and help. Broken bone vs. meds? I just read an article recently, and I don't remember where, but, it was somebody bringing up the issue of med errors in LTC. When you are standing there the moment something terrible is about to happen, nobody can just say, "oh well, I've got to give these meds", yet, on the other hand, the powers that be will tag you in a heartbeat for not answering a call light immediately. When I'm passing meds, I can't just totally ignore what is going on around me.

[Town & Country]

The problem was that there was an antibiotic that got missed on her shift, the even bigger problem was that the patient was admitted the day before and antibiotic therapy was not initiated on that date, so for 24 hours the patient did not start her antibiotic therapy. If we were trying to beat sepsis it was a pretty poor attempt.

So what did you do about the antibiotic not being given the day before?

[beannie]

Wasn't too much to be done about it since the time had already elapsed. It is policy to start the antibiotic within four hours of admission. This did not happen, it was written to start the next day. I still feel bad, I don't feel I should have just changed the time of the antibiotic to be due at 1800 for the future and just be done with it. Thats what some of my co-workers think. It makes me nervous that this is the response to errors. I have made mistakes and learned from them, if I didn't know about them I would not know my weaknesses nor how to avoid repeating in the future. I remember one mistake I made and reported, after a review, turns out there was a pump failure and management made the appropriate changes and an inservice to boot. Just telling someone they made a mistake does not prevent the error from occuring again and may lead to oversight of a bigger problem.

*shortened this post