) How are the people in your healthcare organization treated following an event involving an honest mistake?
Generally speaking people who report an honest mistake are treated fairly well. They receive either consoling or coaching. Unless the error is egregious, it is rare for someone to have disciplinary action due to reporting a mistake. Part of being a leader is being able to talk to a colleague about a mistake and help not only find the root of the problem, but also help them manage their emotions regarding the mistake.
2.) How easy is it to report events that compromise safety in your organization?
It is very easy to report an incident. The software is available on all computers on the hopsital network. The form takes less than 5 minutes to complete for most issues. As a nurse leader, we can encourage the incident reporting process to be as stream lined as possible and to not require superfluous information. It needs to be simple to complete and not take extra time away from patient care. We use a system called ICare. This system is very user friendly and we are able to make sure that the reports get sent to the proper management. If there is a safety issue noted in CAT scan, I as an ER employee am able to make sure that the report is still sent to the CAT scan manager for review as well as my manager to be sure that this issue is being followed up on.
3.) How well are safety occurrences investigated in your organization?
The vast majority of reports seem to be investigated. The individual that reports the issue will usually receive a response from whoever was in charge of the investigation. Investigating the reports is often an extra responsibility on management and this can lead to half done investigations if they are busy with other tasks. To improve the investigative process, either giving dedicated time or having a separate investigator would allow for a more thorough process. With this being said, I have personally never submitted a safety issue that I did not feel was fully investigated. Each of the concerns that I have personally brought forward were acknowledged and resolved in an impressively timely manner.
4.) Does reporting safety occurrences improve safety?
By reporting safety issues, trends can be found. This may lead to process improvements which would prevent the same issues from happening again. By having a just culture that is focused on safety and process improvement nurses may be more likely to report. A previous employer gave coffee cards to nurses who reported incidents. I feel like this is a small way to encourage people to take the time to actually fully fill out an incident report. Many of the things that are reported are fixed by a simple process improvement. For example, one of the more recent reports I filed was regarding inpatient holds in the emergency department. This has been a huge issue for the past 6 months. We will often come into 25+ of the 30 ED beds full of inpatients. We are not set up or equipped to properly care for these patients. My biggest issue was medication passes. We do not stock most daily medications these patients takes as most of them are not emergent medications. Patients were taking their own medications that they brought with them. I brought this issue to management and now the pharmacy brings the patients medications to the ED between 0330 and 0530 for the 0900 medication pass for any inpatients that are still in the ED. This has made a huge difference in being able to care for the patients, and what a simple fix it was!
2. First of all, I apologize if I ever get emotional for this week’s discussion. I think most people will get emotional after hearing this story in person.
This is the main story: I remembered an incidence where my colleague gave potassium to a wrong dialysis patient during a break change. The break nurse did not verify patients according to the protocols. The main nurse told the break nurse that everything was scanned and checked and she verified to the break nurse to give potassium to a patient. The break nurse gave potassium pill to a wrong patient with kidney failure because she did not verify the right patient. Later, that patient got an emergent blood check, luckily, the potassium level was still in the accepted range.
Later, the main nurse came back and figured that the break nurse gave wrong pill to the wrong person. She reported it immediately to the patient, charge nurse, pharmacist, and physician. When asked by the main nurse, the patient replied that she thought she was getting her regular sevelamer because sevelamer pill and potassium pill have the same shape and the break nurse did not tell her what she was giving or ask her name or birthday to verify. Later she said that “they” blamed her for not finishing her duty before taking the break. She was very upset. She quit hospital bedside nursing permanently after the judgment. The break nurse later became the manager of infection control department.
1. How are the people in your healthcare organization treated following an event involving an honest mistake?
– According to the story, the main nurse clearly was not responsible to the incidence. She was taking break according to the time requirement, she did verify patient to the break nurse, and she reported the incidence to responsible parties and to the patient. She was honest. She did everything right. The judgment was not fair. This makes that hospital’s staffs feel not comfortable being honest reporting mistakes or unsafe practices anymore. I was an employee of that hospital. I myself did not feel comfortable reporting what I might have seen wrong over there after knowing the sad story. What if something goes horribly wrong in the future? I honestly do not know.
– What worries me who was “they” that the main nurse mentioned? Was it a panel of people? Or was it only one person? Only that nurse knows.
– As nurse leader, I would want to know who “they” was. I would want to form an investigating panel involving the managers of all disciplines including physicians, nurses, PTs, Its, social workers, even the house keepers and a layperson to represent the patients. I would like to conduct democratic investigations where everybody can have their voice heard before drawing the conclusion.
