A Checklist for Patient Safety - This Nurse Quit, Will YOU?

IS PATIENT SAFETY JUST A BUZZWORD?

Patient safety is a buzzword we hear about all the time. We hear stories in the media, stories from friends and family, and some of us even have our own stories. Bad things happen and we are always looking for someone or something to blame. I know if something happened to someone I love while they were in the hospital, I would do everything in my power to find out the person responsible. But what if it's not a person? What if instead of finding people to blame, we realized that it's the system that is flawed. How do you blame a system? And how do you change it? You can't fire a hospital...and depending on where you live and your access to healthcare, you can't always choose to go to a different hospital if you don't like the one around the corner. If you are a healthcare worker, you can choose to work for a system that truly values safety.

PRESSURE

What are the characteristics of an organization that values safety? Let me show you one that doesn't first, using the story of a nurse called SN. She worked in the same 700-bed, urban hospital for a year after she graduated with an ADN. She worked on an orthopedic unit and was proud of her job - though the $25 an hour she got wasn't much more than what she made cleaning houses during nursing school. The job did have benefits though. SN was scheduled to work three, 12-hour shifts each week, but she was constantly asked to take extra shifts due to staffing issues, and on the rare occasions she said no, she felt guilty. There was always pressure to do more. During her time on the unit, SN was asked to be charge nurse at least once a month, though the position offered no pay incentive.

NO BREAKS

During her time on the unit, SN had a tough time finding a good work-life balance. She had a two-year-old and a husband and was enrolled in a BSN program. Working an average of 4 shifts per week didn't leave time to go to yoga or exercise like she used to. The culture of the unit emphasized toughness. The nurse who trained her (her nurse "mom" as she thought of her), bragged daily about going 13 hours without going to the bathroom. Nurses on the unit constantly complained about not getting a lunch break, but nothing was ever done, and it always felt like they were bragging a little bit too. Her "nurse mom" sometimes teased her about getting her BSN saying, "why do you need that degree - I've been a nurse for 30 years and I don't need to be a BSN to know how to be a good nurse" SN wondered if she was the only person working there who minded the negativity, long hours and lack of break time.

FLY UNDER THE RADAR

Towards the end of her first year, SN had been getting to know a new coworker - a nurse had transferred in from another hospital. It was interesting to learn about how another hospital, the differences in pay, culture, and staffing. The new co-worker told her, "Where I worked before it was considered a safety issue to work more than 3 shifts. We were encouraged to take breaks - it was just a different world there." One day, the coworker stopped coming to work and stopped answering her phone. SN asked the nurse manager about the woman, and was told, "she no longer works here". There was gossip in the break room that her friend came up positive on a drug test. SN's "nurse mom" told her that sort of thing happened all the time. She said, "Keep your head down here, fly under the radar, don't make waves and try to just get along. That's the way to be successful on this unit".

WORK-AROUNDS

SN spent most of her day trying to catch up. There was never enough time to spend with patients, and never enough time to do things the way she was taught in nursing school. In her fifth month on the unit, they instituted bar code administration, but the barcode scanners didn't always work. Once, her "nurse mom" walked up grumbling, "I am so sick of the barcodes being broken! It takes twice as long to give meds now and I am always behind. Will you check this syringe? I've got to give this shot now and I don't have time to mess with that scanner." SN gave the syringe a cursory glance and thought, "she knows what she's doing". Sometimes, SN took shortcuts too- like pulling all patient meds to her cart at the beginning of the day - lots of other nurses did it, and it saved so much time. SN reported the barcode scanner issue several times but finally gave up, not wanting to be a squeaky wheel.

A MED ERROR?

Once during the middle of the night on her fourth shift in a row, SN went to hang a bag of antibiotics. She checked the bag as she took it out of the med cart drawer and took it to the patient's room. The barcode scanner was broken again, so she documented it and hung the bag the "old fashioned way", tossing the empty bag in the trash. The next evening, SN overheard a nurse discussing how angry the patient's family was because they found an empty antibiotic bag in the trash with a different patient name on it. SN felt her stomach drop. She went to look in the antibiotic drawer and realized that the same antibiotic had been ordered for two different patients in rooms right next to each other. She was so relieved to discover that the patient had gotten the right antibiotic, thinking "no harm, no foul!" SN wondered if she had somehow hung the wrong bag, or if it had been the nurse working the shift before her? SN thought about talking to the nurse manager but finally decided to just keep quiet, thinking, "after all, no one was hurt".

PATIENT SAFETY

The hospital where SN worked instituted a new patient safety initiative during her final month on the job. Part of the initiative involved daily screen savers advertising patient safety information. One of the screens really stuck in her mind, listing some of the top reasons for medication errors. They included fatigue, staffing ratios, lack of self-care, burn-out, inexperience, not having a higher degree and a poor safety culture. SN was worried because so many of those characteristics applied to her. Another screensaver advertised a new position called a Patient Safety Officer. The PSO is expected to keep track of errors on each unit, help with the investigation of errors, and report to a patient safety committee each month. SN was interested in patient safety and thought it might be a good way to support patient safety on the unit, but she found out the position didn't come with any extra pay, and that a BSN was required.

GUILT AND SHAME

The screensavers finally started to get to SN. It seemed like every day, they mentioned some horrible error involving patient harm. The statistics made her wonder how nurses could be the most trusted profession. She resolved daily to be more careful, thinking "not on my watch". The more SN learned about patient safety, the more frustrated she got. It seemed like the hospital knew what changes needed to be made to improve patient safety, but nothing was ever done. She learned one day that the rate of patient harm hadn't changed in 20 years. "What's the point in even trying"? She started to think, "it feels like no matter what I do, I am going to make a mistake...and I might end up killing someone".

FED UP

SN finally quit her job and quit being a nurse. The negative work environment, lack of support and poor working conditions led to burn-out for SN. SN is now working as an administrative assistant at a local college. She has predictable hours, no weekends or night shifts, good benefits, and she makes more than she did as an RN. She always gets her lunch break, and goes to the bathroom whenever she feels the need! SN misses being a nurse and hates that she is still paying off her college loans, but she continues to think she made the right decision to leave. She no longer worries about accidentally killing someone. A few months after she quit the hospital, an infant died there due to a heparin overdose. The news reported several nurses had been fired for not using the bar code administration system correctly. SN continues to feel that she got out just in time.

WHERE ARE YOU IN THE STORY?

As you read SNs story, did you see yourself in any part of it? I wonder if any of it triggered strong feelings for you. So many nurses work in on a unit like the one in the story. So many of us work under these conditions, or worse. I am sure you have read before that about half of all new nurses quit the profession before they've been a nurse for even a year. And what does this have to do with patient safety? I started off talking about systems issues versus individual issues. In SNs story - how many of the challenges she faced could have been solved by systems changes? My ultimate question is, we expect so much of ourselves and of other nurses, but why don't we expect more of our healthcare institutions? What standards should we hold them to? What characteristics should we look for when looking for a job as a nurse, or when looking for a healthcare facility when we or someone we love is ill?

SOLUTIONS

Attached is a checklist of things to look for. I am interested to hear what I have missed - what would you add?

Patient Safety Organization Checklist.pdf