A month has literally flown by and the world is fraught with change, financial forecasts of inflation, income insecurity, weather events, and a weeks long conflict in eastern Europe. The time to pause and listen to the silence is a challenge, there are more demands on one’s time to get stuff done; in a timely manner, adapting to time constraints, and limited resources. In the past week the news of a nurse criminally charged and found guilty related to a key task of nursing–medication administration–highlights the risks that pre date the pandemic.

Patient care is a complex affair, as an experienced, knowledgeable, and skilled RN I have built my practice as many have through education, engaged in reflective quality assurance, followed the path of patient safety and taken a lead for a diverse, evolving team. There can be a number of systems risks that influence patient safety, since the report (2001) Crossing the Quality Chasm: A New Health System for the 21st Century the safety pathway has evolved to be more effective, reliable, and resilient. The culture of health care has seeded, germinated, and been harvested to yield trust, transparency, professional accountability (disclose errors/near misses), and learn from failures of systems and processes. Evidence-based practices designed, tested, adequate resources provided, and databases replete with examples of how patient safety is a necessity and the root causes of incidents that occurred, the learning that was done and follow through.

When patient safety is a collective goal in a just and fair culture, the staff know that incident reports are useful and reflect good practice. Feedback on findings is instrumental in policy changes, equipment upgrades or additional resources; for our public needs to know they can trust our organizations. In the rare circumstances that an error arose from failure of an individual to rescue, follow policies, report an event and/or misrepresented the facts it is a performance management issue.

Increased fear within organizations related to the patient safety practices now in use (hard work achieved in two decades and more), could be an outcome of the criminal case. Specifically, a RN administered a medication that was complicated by human error and a medication dispensing system. The holes in the swiss cheese (To Err is Human–Reasoner) lined up and a sedative was not given instead a paralytic agent was administered. From the information available the incident has mixed root causes, review of the case details indicate some performance issues, definitely system issues, and this occurred before the pandemic.

The pandemic is now a factor, as the system issues predate the time period of COVID-19, staffing challenges, medication dispensing systems that can be overridden, inconsistent in the naming of medications i.e., Trade names Benadryl vs Gravol; generic names diphenhydramine and dimenhydrinate. I recall many years ago the memory hack ‘p’ pruritis (itchy) and ‘m’ motion sickness and the medication “rights” way back when were 4 now they’re 8 or Google scan showed 5, 10, 13! The task of giving meds is complicated and interruptions are sadly frequent to continuous. The responsibility is arduous and at the organization level we need to ensure that a ‘just’ culture exists.

None of us can be perfect, we are on a path to deliver excellence and when an adverse event occurs the feeling nurses have is somewhere between no problem to physically ill, distraught, worried. Criminalizing the adverse event instead of supporting the staff is a setback for patient safety. The outcome could be more lives lost. If a fully loaded passenger plane crashed every day there would be an action plan. When errors in patient care occur the impact can be similar, there needs to be value in teamwork, support, communication, reliability, accountability, transparency and remember to report near misses. These are actually indicators that an adverse event could happen, and support your colleagues. Most people go to work to do an excellent effort, every shift, and the leaders need to ensure the systems supports are available, workload is resourced, and contingency plans exist for staffing challenges, or automated dispensing systems that miss the mark of patient safety. Namaste

Categories: Uncategorized

Paula M

Registered Nurse Storyteller, Healer, Scribe, Transformational Leader