Why Do We Continue to Harm Patients?

This article describes several medical errors and starts a discussion about the impact of medical error on patients and nurses. Your input is requested on this important topic. Nurses Safety Article

  1. Have you ever made an error that caused patient harm?

    • 6
      Yes, more than one
    • 6
      Yes, just one
    • 23
      No, not once
    • 14
      I am not sure

49 members have participated

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 few days, as you drift in and out of consciousness, you realize from the conversations going on around you that you have been in the ICU for three weeks. Over the next weeks of recovery, you come to realize that during surgery - a standard hysterectomy for a diagnosis of uterine cancer - your bowel was nicked. Your post-operative pain was ignored for almost 36 hours, and you ended up septic and in the ICU. This story is from Anatomy of Medical Errors: The Patient in Room 2 by Donna Helen Crisp1 - she was a professor of nursing at the UNC school of nursing and this happened to her.

In another book about medical mistakes, Wall of Silence2, Rosemary Gibson and Janardan Prasad Singh, share horrifying stories of medical error, including a widower whose wife died of cancer that was spotted three years before her death but never treated, a woman who died from sepsis after hemorrhoid surgery, a man who was supposed to have his left lung operated on, but had the right one operated on instead. On the ProPublica Patient Safety Facebook page3 you can read daily accounts of the suffering of individuals from medical error. These are stories from people who have been harmed in our care - in the care of a system that was supposed to at least try to heal them.

PATIENT SAFETY

I am obsessed with patient safety and the prevention of harm from medical error. Wherever I go, I talk to people about my obsession, and people open up to me. At the National Patient Safety Conference in 2017, I bonded with a sales-rep over the death of his father, who had gone into the hospital a healthy 82-year-old needing a routine procedure. He died there 6 months later of pneumonia. At a local safety conference, I listened to a young nurse tell a roomful of her peers about an insulin error she was involved in. She bravely recounted her story so that we could learn from it.

A report in 2000 by the Institute of Medicine4 estimated that in healthcare, about 40,000 people die each year from medical error (this number is a gross underestimate - current estimates put deaths from a medical error at more like 400,000 people5). The IOM used an analogy that has haunted me since I read it. It is as if a jumbo jet, fully loaded with passengers, crashes each WEEK and there are NO SURVIVORS. If that happened, don't you think someone would get upset? And yet in healthcare, because these are silent, individual deaths, often covered up by shame, secrecy, and even illegal activities - nothing is done. There is no huge media circus each time one person dies as a result of a medical error, but the cumulative effect is catastrophic.

IMPACT

And what about the impact -- the harm done to patients and families, the needless millions of dollars spent by individuals, healthcare organizations and taxpayers, the emotional suffering of everyone involved - patient, family member, nurse, doctor...the entire healthcare team becomes the victim when an error occurs? The culture of blame and shame so rampant in health care adds to the impact of error by making it extremely difficult for those involved in errors to find support. Victims of medical error often suffer alone, in silence, isolated by an event over which they had no control.

LET'S TALK

Let's open a dialogue. I want your stories, but more importantly, I want your solutions. As nurses, we are in a prime position to impact patient safety because WE know the patient best- that's our job. We are taught in nursing school to "be careful" and to follow the five (or six, or nine, or 12) rights to prevent error, but despite this - nurses continue to make mistakes. In fact, it is unlikely that a nurse will complete their career without making an error6. Does that mean nurses who make errors are bad nurses? Does this mean they just weren't careful enough? Perhaps something else is going on? The modern patient safety movement suggests that instead of focusing on individual responsibility, we focus on SYSTEMS causes for errors - things we can change about our environment, working situation and organization to reduce harm from error.

What works for you? Please share some success stories with me as well as mistakes. I am going to be writing a lot about this topic in the months to come. I will be sharing interviews with nurses involved in error, guidelines for how to "mistake proof" your practice, and information you can USE. Keep your eyes open for safety checklists you can share with friends, family, and patients to prevent harm.

ONE THING

What ONE THING would you do today (the sky is the limit here folks) to reduce harm to patients? To get some ideas and solutions go to my favorite source - the National Patient Safety Foundation/Institute for Healthcare Improvement (NPSF/IHI). If you can't find any ideas there, try the Agency for Healthcare Research and Quality (AHRQ).

REFERENCES

1. Anatomy of Medical Errors

2. Wall of Silence

3. ProPublica Patient Safety Site - Facebook

4. Kohn, L., Corrigan, J., & Donaldson, M. (2000). (Editors). To err is human: Building a safer health system. Washington DC: National Academy Press.

5. Classen, D., Resar, R., Griffin, F. (2011). Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30, 581-9. doi: 10.1377/hlthaff.2011.0190.

6. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41.

7. NPSF/IHI

8. AHRQ

Specializes in PeriOp, ICU, PICU, NICU.

The 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.

What 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.

To 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.

Specializes in Oncology, Home Health, Patient Safety.
OP, 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.

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.

Thank you for pointing out some other good articles on this topic. I agree - focusing on both systems and individual factors is important. I like knowing there are safe systems in place for those times when, despite my best efforts, my critical thinking is not at its best. I do have those moments - I wish I didn't. I hate being human sometimes!

Specializes in Oncology, Home Health, Patient Safety.
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.

Don't give up. Join the ANA and give $5 to the PAC, get informed, make some phone calls - speak up. It all helps. If we get laws in place, then hospitals will have to follow them.

Specializes in Oncology, Home Health, Patient Safety.

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?

I appreciate your comment because it shows I didn't do a good job of making my point. I agree with you about using critical thinking and the 5 (or however many it is) rights. I agree that nurses need to continue to be highly trained and do their jobs in the manner you describe. I also think there are incompetent nurses out there who should be disciplined or fired for their role in error. What I don't agree with is blaming the nurse without exploring possible additional factors that may have played a role. If we simply blame the nurse, and then fire the nurse - we have lost the opportunity to examine all aspects of error. The blame and shame culture so common in health care prevents nurses from talking about or admitting to error and I think we lose a lot of data from those unreported errors. I think changing our culture to one of open transparency might go a long way towards saving patient lives.

I don't think supporting nurses, and supporting in-depth error analysis means that I don't care about patients or patient safety. I am definitely trying to protect patients. What I am doing is suggesting its complicated - and that multiple factors play a role. Knowing what all those factors are may allow us to prevent error in the future. Thanks for your patience as I learn how to make my point with the written word - it is challenging!

I hope that helps clarify my comments. I welcome future questions - this sort of dialogue is how we all learn, and I think continuing to learn is the best thing we can do as individuals to promote patient safety.

Specializes in NICU.

Better staffing ratios! More nurses = more time/attention devoted to each patient. But, i think that would involve increasing the perceived value of nurses.

You see, the majority of the work I do every night for my patients is not of monetary value for the hospital. Unlike the way that respiratory therapy or speech therapy is billed, with itemized billing for services rendered, nursing care is a huge, homogenous blob of time. No one is itemizing the care I give in a bill - and therefore, in the perception of accounting personnel, my efforts are not as valuable. There's no nitpicky list of every little bit of care I give. Even though it is documented, the system simply isn't set up to bill for every facet of nursing care. (Imagine THAT bill!)

I don't know what the answer is to that problem. Maybe an addition to Epic that combs through the chart for all those specific cares? That might work in the big hospitals like mine, but how would it work in a TCU or LTC?

Speaking as someone who had made certain mistakes, and one in particular that involved a lapse in my own judgement which cost me dearly, I feel that safety should always be our number one concern - whatever branch of nursing we are in.

I agree with those who say better staffing ratios, better education, and better safeguards should be put into place. At the end of the day though, errors should be blamed on nothing and no one but the person committing it. We are Human, and our mental faculities are there to be used.

I agree with those who say better staffing ratios, better education, and better safeguards should be put into place. At the end of the day though, errors should be blamed on nothing and no one but the person committing it. We are Human, and our mental faculities are there to be used.

I guarantee you don't really believe that. With regard to nursing it's yet another charge that can't be followed through to its logical conclusion. Maybe you are just viewing it in a very limited context. We deal with scenarios not infrequently where we cannot humanly perform in a manner that prevents the ability for someone to charge us with a technical error, and whether we get charged with it or not just happens to be at their discretion. We are constantly prioritizing and trying to make good decisions in less than ideal circumstances. I have no problem with that and I accept it as part of my role, but I will insist that this conversation not go off the rails with nonsense.

When you decide to delay obtaining a stable patient's vitals in order to care for a more urgent matter first, for example, you are guilty of a technical error (not following policy regarding the patient whose vitals didn't get taken according to the proscribed schedule).

I have no desire to be rude, but I feel very strongly that your exact line of thinking is demoralizing and ultimately dangerous in and of itself.

I've only been at this for a short time but poor medical reconciliation makes for medical errors. A lot of patients, especially those from SNF, come in with boggy histories and charts and they are on multiple medications. Some aren't able to communicate about allergies. Paperwork from the SNF isn't always available or lost.

I love the fact you are discussing the topic. But, truly what improvements have the hospitals employ? In my opinion tons EXCEPT staffing or assigning patients by acuity. I work in the OB world and most would assume that's is rather easy but on the contrary its quite the med/surg floor....lol I hate to be a negative nelly but nurses are seen as an expense and therefore the budget always comes first. So, we work short staffed and even if staffing it good someone will be sent home. So until we are seen and more than an expense and the patients are truly seen as more than a $$ cause lets be real its all boils down to profit. Most hospitals won't make a profit if there is adequate staffing on a daily basis.

I agree with those who say better staffing ratios, better education, and better safeguards should be put into place. At the end of the day though, errors should be blamed on nothing and no one but the person committing it. We are Human, and our mental faculities are there to be used.

Pointing a finger is the person is not the solution and blaming the persoon will only result in less errors being reported. Usually after doing a thorough assessment sometimes there is a break in the system. And yes we are all only human and not little robots ...maybe we will be replaced by them one day who knows...lol

Specializes in Oncology, Home Health, Patient Safety.
Speaking as someone who had made certain mistakes, and one in particular that involved a lapse in my own judgement which cost me dearly, I feel that safety should always be our number one concern - whatever branch of nursing we are in.

I agree with those who say better staffing ratios, better education, and better safeguards should be put into place. At the end of the day though, errors should be blamed on nothing and no one but the person committing it. We are Human, and our mental faculities are there to be used.

Thank you for being open and sharing - your courage in sharing is so supportive of the healing that can take place when we lean in, when we say "we are all in this together" vs. judging and shaming.

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