In 2004 the report Keeping Patients Safe: Transforming the Work Environment of Nurses cited this example:
I was a ‘new nurse’. I’d been practicing only a few months when I was assigned an elderly patient who was scheduled for abdominal surgery that morning and needed a urinary catheter. I knew about, but hadn’t performed this procedure before, and neither had the other nurses on the floor- we were new graduates. I asked my head nurse if she would supervise me while I placed the catheter, but she was late for a meeting and assured me that it wasn’t difficult and I would be fine.
I went to get the supplies but there were no prepackaged catheterization trays on the floor. I ran to the floors above and below, they were out too. As I passed the nursing station, the clerk told me that OR wanted to know where the patient was. I began to round up the supplies one by one.
I got the last sterile prep tray, sterile catheter and gloves, antiseptic for cleaning, and drainage bag. I opened the tray, prepared the patient, put on the sterile gloves and realized I hadn’t opened the bottle of antiseptic before putting on the sterile gloves and that the routine sterile prep tray didn’t contain what I had expected. There were no more gloves in the patient’s room. I went to get more, cautioning my patient not to move and leaving my sterile field unattended. As I passed the nursing station the clerk called out: "OR called again and they are angry they want to know what is keeping the patient. You are backing up the OR schedule.” I got the gloves and with trembling hands, uncertainty about the sterility of my sterile field, and not the best of technique, inserted the catheter. A few days later, I was charting my patients and seated next to the patient’s residents who exclaimed, "Mrs. Y has the worst UTI I’ve ever seen."
I didn’t say anything. I was ashamed and afraid, and besides the resident was already writing the order for antibiotics. There was nothing more to be done. What would be gained if I told anyone?
The crucial questions readers are invited to answer in this blog are: To what extent has progress been made in the last 6 years? In your experience has patient safety advanced to the point that an example like this would not exist today?
It is a well known and proven fact that nurses are the health care professionals by virtue of time spent with patients and their numbers that will have the greatest impact on health care quality and therefore influencing their work environment will have the maximum reward.
In analyzing the example above the usual tendency would be to focus on the individual nurse’s competency and to try and fix the problem at the individual level. But would that action prevent future errors from taking place? We note that the nurse decided that there would be no advantage in speaking up and she was probably right. In fact she was cognizant of her own inexperience and had tried to access the expertise of her superior. Yet there was no one she could rely on for assistance or support. She was under pressure to keep to the schedule for OR. However, the equipment she needed was not available in a timely manner and she had to make a substitution. None of those factors were within her control and were a definite contribution to the adverse event the patient suffered. She also did not feel authorized to send the patient to OR without a catheter. This is an example of how workplace environment and systems do not support a successful health care outcome or contribute to successful nursing. The goal of the report was to alert health care organizations to these systemic failures and for them to make positive changes.
I knew it was going to be a busy shift, with elective surgery admissions from the post anesthetic care unit, direct admissions from the clinic and anything else the ER sent us. Each nurse already had 5 patients each, some of them needing a lot of care. There was no secretary available to put charts together and the nurse manager had already said there was ‘no nurse in the system’ to send to help us.
When the ER called to report on my second admission for the shift, I asked if they could please hold the patient until I finished a blood transfusion on one patient and completed the admission on the patient from the recovery room. The nurse from ER told me the patient would be up in 5 minutes and hung up the phone before I could say anything else. I called my supervisor and explained that we were overloaded with the activity on the unit. I asked if she could send another nurse to help or assign the admission to another unit.. She said she would ‘look around’ but there was no one she could send immediately. I asked if she could delay the admission until I could stabilize my other patients. She replied that ER was backed up and I had to take the patient right now or she would have to ‘write me up’.
When the patient came, I had to leave a new mastectomy patient who was crying each time she looked at her surgical dressing and whose patient –controlled analgesia pump was alarming. I left her promising to return as soon as I could and went to check on the ER admission. The shift ended and I never got back to her except to check her IV fluid totals.
It was only after I got home that I remembered that I hadn’t put the allergy band for seafood and penicillin on the ER admission. I called the unit just as the patient was being sent to OR and asked them to put on the allergy band and note the front of the chart.I could not rest. Every time I closed my eyes I thought about the fact that she could have been prepped using ad iodine scrub or they could have given her penicillin as a peri-operative antibiotic. A reaction from either could have been fatal.
In the bid to curtail costs two events have occurred in the recent past: Health care centers have reduced nurse staff and these fewer nurses must work more hours. Both have been correlated to increased probability of more errors and adverse events such as avoidable readmissions. Nurses may also feel financial pressure to work more. Nurse fatigue also increases as the hours and workload increase. No degree of training, motivation or professionalism is able to compensate for lack of rest. Fatigue has been proven in many professions to have a detrimental effect on productivity. Health care has been one of the last professions to address this issue with policy changes.
The American Association of Nursing has reiterated both the individual nurse’s responsibility to act ethically by considering how well rested he or she is before accepting work and also at the organizational level to ensure that nurses who work are well rested. Several states are banning mandatory overtime for nurses. The ANA has also recommended that nurse salaries should reflect education, training, and experience.
The above example shows again how nurses must cope with events that impact their time to provide direct care. Such tasks as phoning, and documentation cause valuable time to be lost that could be used to care for patients. Nurses must also deal with interruptions and the expectations of other parts of the medical centre as well as the attitudes of their superiors whether supportive or not.
Nurses are the best positioned of any professional in an organization to make productive observations on both patients and processes. Giving them a say in their own workload is a key recommendation of this report, for example by being given the power to delay admissions into a unit. Have health care organizations taken this to heart? Has this been the readers’ experience?
In the example the nurse involved did try to communicate the need to wait but she was overruled because of pressure in the system. Part 2 will address the organization’s responsibility in patient safety through transformational leadership and the culture of safety.
http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workplace/NurseShortageStaffing/NurseFatigue/EmployersRole.aspx
http://book.nap.edu/openbook.php?record_id=10851
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