Tattle Tales

i'm all for reducing infection rates. (54 weeks without a bloodstream infection here!) but i think your facility is concentrating unduly on documentation and potential disciplinary action. we've had marvelous results without going that far.

we have our central line checklist, our hand washing audits, etc. everyone who witnesses a potential unsafe practice is empowered to call a stop to it right then and there. most of the time it isn't an egregious error deserving of discipline -- it's just a small oversight or momentary lack of attention that is easily remedied when brought to attention. everyone is pretty matter of fact about the whole thing. "hey doc, i think your sterile glove may have touched the bedrail." "oh, geez. hang on while i change it. you got another 7 1/2?" our checklist is worded so that we don't have to document anything unless we called someone's attention to a possible unsafe practice and they ignored us. or we ignored them. you forgot to wash your hands? wash them now, then.

without the threat of "disciplinary action", everyone is fairly honest about recording things as they happen and pretty amenable to fixing problems as they're noticed. if there's a pattern of "no, my glove didn't touch anything" or "i washed my hands but you just didn't see me," that gets documented and counseled but again, i caution against jumping into discipline.

I see unsafe practices all the time and as a new nurse I am reluctant to speak up. I am trying to develop the courage and aplomb to do so effectively. I like Ruby's advice above. It sounds like her staff are all mature adults with a collegial attitude. My last attempt to bring up an issue of safety with the person whom I thought was appropriate was met with a dismissive statement that let me know my concerns would not be addressed or even briefly considered. It was quite clear that if I wished to maintain my employment, I had better conform, and go with the flow. Other nurses I consulted, involved in the same procedures, had concerns too, but also had decided not to question the practice. I feared for my job. I will address it further, but not til I am certain I'm not the proverbial bull in a china shop or the deer with the target painted on its flank.

Here are the latest: Injection preparation -- people seldom careful about not touching the parts of the syringe that are to be kept sterile -- i.e., hub, connector, plunger. Even in so-called educational videos, people are grasping the syringe by the plunger, not the flange on the plunger, as I was taught and my research confirms is correct.

And this one: drawing up multiple syringes from a multidose vial by leaving a needle in the septum, then detaching and reattaching that needle to successive syringes, with bare fingers touching the hub of the resident needle and syringe connector, occasionally and unavoidably, touching the needle itself and the septum. (No handwashing facilities or hand sanitizer in sight.) Since this needle will eventually be discarded, I can see why someone might assume no harm is done. But CDC forbids the practice, stating that it allows direct entry of microorganisms to the vial, if I understand the guidelines correctly.

Filling multiple syringes of liquid suspension without first shaking the bottle to remix the suspension. I was trained "do not shake the vial," when the package insert clearly states "must shake the vial before each dose is drawn up."

And several other violations of recommended practices.

These are my latest concerns. Am I overreacting? What is the appropriate response?

Advice welcomed.

I don't view it as tattling, I view it as Patient Safety. We empower our staff to professionally correct identified deficits at the time of occurrence. We have a PI program to monitor policies/procedures and have the staff collect and analyze the data. Everyone is involved and there is no disciplinary counseling unless it is repeated. In a non-punitive just culture counseling is viewed as a punishment, which is what it sounds like your institution wants it to be. Maybe if it was presented in a more educational manner, your outcomes would improve as well as patient satisfaction. Try it, it works!