Over a decade ago a patient was administered fatal dose of chemotherapy. The State Department of Patient Health (Massachusetts) and the Joint Commission on Accreditation of Health Care Organizations found the attending nurses were not at fault, as they had done all verification and followed directions. Those organizations found the following system errors:
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The investigative protocol document, the only source of information for confirming the dosage, was flawed The doctor had based his order on that document. Also there was no computer pharmacy check system. Still the state board of nursing sanctioned 16 nurses.
Another example, a woman with a prenatal history of syphilis gave birth to a baby. There was no document to treat syphilis so the neonatal and pediatric infectious disease experts prescribed penicillin G 150000 units /kg by intramuscular injection. The pharmacist misread the dosage and sent it to the hospital in 2 syringes, because the hospital did not have a unit dose system. This dose would require 5 IM injections so 3 nurses consulted a drug reference book and decided to give the drug by slow IV push. They were unaware that there were 2 forms of penicillin; viscous to be administered only by IM, and aqueous which could be given by IV. The baby died and the nurses were indicted. Trial evidence showed 50 system failures by the Institute for Safe Medication Practice, including the manufacturer’s warning on the syringe was difficult to see, the available reference was ambiguous about the route of administration, besides the errors already mentioned.
Has progress been made in understanding that it is often system breakdown rather that individual incompetence that leads to adverse events? What have been your experiences?
An organization tends to move in stages until a culture of safety is established.
In the first stage studies have been conducted that show there tends to be an imbalance between production efficiency, reliability and safety with an emphasis on the former at the expense of the latter. In stage one profit and costs are goals. Staff are viewed as part of the system and are valued only on how they contribute to the organization.
A good example of this is a health care organization that cut back on nursing staff to keep within the budget. At times a disconnect may exist between top management and front line workers who are mainly nurses. As a result patient care suffers. As nurse job satisfaction decreases staff turnover increases and a negative cycle begins. The report goes as far as saying that staffing practices can damage trust between nurses and management.
A hierarchical management style can cause an us versus them mentality. Management simply copes on a day to day basis with no long term strategy or vision .If the executive are aware of mistakes its response is to assign blame and create more rules.
Failure in patient care can be either errors or problems. Errors are incorrectly done tasks. Problems are disruption of nurse’s ability to carry out the task because of circumstances, resources, or conditions are beyond the nurse’s control. Think of example one in the last article where the nurse had to run to 2 floors and was still unable to acquire the necessary supplies.
Most failures are problems not errors.
However, nurses correct most problems without communicating or trying to find the cause of the problem. They do this because nurses feel that is what the problem is expected of them, to be self reliant and independent. Also time is often at a premium when hospitals are short staffed. Communicating the problem or asking for help is seen as a negative characteristic (note in the second example of the last article the supervisor responded that the nurse would be written up if she didn’t accept the new patient from the ER.).
Second order problem solving enables the organization to see the failure as a learning opportunity that can prevent future occurrences. Thus they need to create a climate of trust where nurses feel free to report problems without fear of reprisal.
There are three other management practices that will contribute to a culture of safety in a health care organization. They are being proactive in the process of change, ensuring worker involvement in decision making of work design and workflow and establishing to health care organization as a learning organization, by enabling workers to continually acquire new knowledge.
Being proactive involves vision to look beyond the day to day operation of the health care organization. Transformational leadership pursues goals with their followers and is characterized by two way communication and the exchange of ideas which leads to decentralized decision making.
Transformational leadership not only embodies trust where workers can contribute to improvement by for example, reporting errors without fear of punishment but also will change workers’ beliefs and practices. This must involve nurses participating in all levels of management in the medical center.
Vigilance in prevention of potential errors, detection, analysis, and correction of errors are important as are the recognition that often it is system failure that contributes to errors. Supporting staff and the encouragement of continuous learning will create a culture of safety. This requires commitment over a period of time and a demonstration/ willingness by management to lead by example. Progress must be continually evaluated by surveys and feedback. Staff must feel comfortable identifying inefficient high risk processes and systems and conveying that information to executives. Then management will be able to support successful nursing care by designing work environments that decreases the probability of errors. Leadership success is achieved when employees are engaged, there is mutual trust, and information is shared that will increase safety.
An effective error reporting system is non punitive and allows for a description of the incident instead of checking boxes on a form. It is very important that the report be analyzed by professionals who have hands on experience and an understanding of nursing care. The error reporting system needs to provide feedback in a timely manner so that nurses can see that management ‘walks the talk’.
Technology has increased the development and volume of new knowledge this means that nurses and other professionals must continually update their knowledge to stay current. Management needs to model and support this ongoing acquisition of new skills. It is crucial that new information that supports nursing care be transmitted to every department in a timely manner for it to have a positive influence on patient care.
All these aspects must be implemented at once to achieve success.
Examples of hospitals that have been successful are known as magnet hospitals. The characteristics of a magnet hospital are a trusting atmosphere, nurse autonomy and accountability, supportive management, control over nursing practice, and educational support.
So the questions are: To what extent do nurses feel responsible for the culture of safety? How much can or should nurses do to effect change? Reader feedback is welcome.
Source: http://book.nap.edu/openbook.php?record_id=10851
Article © 2010 My Nursing Uniforms.com / Young Lion Incorporated.
