How Nurses Can Avoid the Medical Error Nightmare
Medical errors are a nurse’s worst nightmare. Most of us are familiar with the knee-buckling, blood-draining panic that sweeps through you when you realize you’ve made a mistake, whether it’s the wrong med, the wrong patient or the wrong dose. The possibilities for error are endless and each time you start a shift, you know they could happen to you.
Of course, you learned best practices in nursing school, but the rapid changes in medication, technology and procedures would test even the most conscientious clinician’s sanity. A little extra caution could save your career and maybe even a patient’s life. ‘
A COSTLY PROBLEM
Medical errors are a persistent blight on America’s healthcare system. An article in the September 2013 edition of the Journal of Patient Safety reported jaw-dropping figures: Each year, between 210,000 and 440,000 hospitalized patients die because of preventable adverse events (PAEs). Some of those deaths are close to home. The Department of Public Health recently fined 13 California hospitals a total of $14.1 million for mistakes that allegedly resulted in five patient deaths, one case of severe neurological damage, an unexpected code and a retained surgical sponge.
Who pays for these medical errors? We all do, of course. For healthcare providers, the cost is measured in fines, punitive court judgments and legal fees. For patients and families, the cost is too often disability or death. As nurses, we pay with our hearts. We’re naturally concerned about legal consequences and the risk of punishment, but we care deeply about our patients and the perceived betrayal of trust when we make an error, which leaves us not only afraid but ashamed.
Unfortunately, nurses typically make more errors than any other category of healthcare provider. We’re the shortstops of healthcare: We see the most action and we drop the most balls. The good news is that it doesn’t have to be that way if you stay on top of your game.
AVOIDING MEDICATION MISTAKES
A complete list of every possible type of medical error would fill many books. Some mistakes are the result of serious institutional problems like poorly designed or bug-ridden electronic medical records systems. Others — including many of the most common PAEs involving nurses — are individual mistakes that can be avoided with proper diligence.
Unsurprisingly, many common errors involve medication. If you can’t recite the Institute for Healthcare Improvement’s Five Rights (right patient, right drug, right dose, right route, right time), you probably shouldn’t be practicing at all, much less passing meds, but it’s scary how often nurses miss at least one of those five.
Here are some tips to help keep us all on the right path:
Beware of look-alikes. New medications appear almost every day and many of those meds have names that look or sound too similar for comfort. Make sure you’re familiar with the latest Institute for Safe Medication Practice (ISMP) list of confused drug names, which includes look-alike and sound-alike drugs that have been involved in medication errors. Wherever possible, store look-alike medications in different areas and group drugs by category rather than alphabetically.
Watch for high-alert meds. The ISMP also issues lists of high-alert medications “that bear a heightened risk of causing significant patient harm when they are used in error.” Based on error reports from a variety of sources, the list is designed to warn healthcare providers of medications that may require special handling to reduce the risk of serious errors. Check out the link and make sure that high-alert and other dangerous medications such as neuromuscular blocking agents and concentrated potassium chloride are stored separately from commonly used, less-risky supplies.
Sterile doesn’t mean safe. There are many alarming stories about patients who were administered wrong solutions via wrong routes because containers on sterile fields were left unlabeled. In one particularly terrifying incident, a Seattle patient died because she was accidentally injected with cleaning solution. Label everything and don’t assume you know what’s in a bulb syringe, medication cup or other container just because it’s in the sterile field.
Oh, that tricky tubing. Back in April 2006, The Joint Commission issued a Sentinel Event Alert about tubing misconnections, which are a common cause of medication errors. There are various safety recommendations, but the most important are:
Trace it back. Always trace every line back to its origin before connecting or disconnecting anything.
Turn on the lights. That patient you’re trying to tip-toe around would rather deal with the glare than the result of your attaching the wrong solution to the wrong line.
Please don’t touch. Remind patients and families that they should never reconnect lines themselves.
Label all tubes and catheters. This is particularly critical for high-risk tubing like epidural, intrathecal and arterial catheters.
BUILDING A SAFETY NET
There are a number of simple strategies you can follow to reduce your risk of common errors. Here are just a few:
• Quiet, please. Perform critical tasks in distraction-free zones whenever possible.
• Slow down. It’s always better to take an extra moment to be sure of what you’re doing.
• Communicate better. Keep critical communications complete, concise and to the point, following the SBAR (situation, background, assessment, recommendation) model. (Click here for this communications strategy.)
• Don’t cheat. Taking shortcuts with established safety procedures can lead to disaster.
• Learn to love technology. Especially if you’ve been practicing for a long time, new technology and new systems may seem like a pain, but they can enhance patient safety.
• Empower patients. Involve patients in what you’re doing and encourage them to speak up if they have questions.
• Educate yourself. Additional safety information can be found in resources like the Agency for Healthcare Research and Quality’s voluminous Patient Safety and Quality: An Evidence-Based Handbook for Nurses and the website of the National Patient Safety Foundation. Take advantage of them.
WHEN MISTAKES HAPPEN
Everyone makes mistakes, and when you do, it may be very tempting to keep it to yourself. While the American Nurses Association recommends a “Just Culture” approach that focuses on correcting and avoiding mistakes rather than punishing people for them, not all organizations follow that model — and the penalties can be severe.
However, not reporting an error is likely to compound the harm to the patient, possibly with lethal consequences. Furthermore, if your hospital does take a punitive attitude toward mistakes, things will go even worse for you if you weren’t the first to speak up. It’s always better to put the safety and well-being of your patient first.
PAINFUL DETAILS, LASTING SOLUTIONS
If you’re involved in a medical error, even if it wasn’t your fault, don’t be surprised if you’re asked to help figure out what happened. In the case of a “sentinel event” (an incident that results in death, injury or the risk of death or injury), the Joint Commission requires healthcare facilities to use a process called root cause analysis. This involves a standardized list of 24 questions to determine what factors were involved in the event with an eye toward preventing future incidents (although institutions sometimes use the same process for other purposes).
Sometimes, healthcare organizations also use what’s called failure mode effects and criticality analysis (FMECA), which involves looking for potential weak spots in the organization’s procedures. FMECA isn’t exclusive to healthcare — it’s also used in industries like aerospace to identify possible failure points so that corrective measures can be taken. FMECA is usually a more proactive process while root cause analysis is usually used after an incident.
Either process can be painful and frustrating for the nursing staff, involving a lot of intrusive and time-consuming questions about minor procedural details. However, this type of analysis is very useful for getting to the bottom of medical errors and reducing the chances of their happening again, both at your hospital and others like it.
FACING THE RISKS
Whether you’ve been a nurse for one day or 40 years, the risk of making an error is something you face every time you clip on your badge. Some of that is just the nature of our profession: Nursing is important work that demands a high level of skill in a fast-moving, stressful environment. However, by following these tips and taking extra care with everything you do, you can reduce the odds of putting your patients or yourself in harm’s way.
Sue Montgomery, RN, BSN, CHPN, is a critical care and hospice nurse who writes on healthcare issues. She is a member of the Hospice and Palliative Nurses Association and American Medical Writers Association.
Don’t let guilt and doubt sabotage your nursing career. Here, a therapist specializing in healthcare issues shows how positive self-talk can help you rebuild confidence and turn a mistake into an opportunity for growth.
by Mary Beth James, M.A., LMFT
Nearly every nurse makes at least a few treatment errors over the course of a career — some trivial, some serious. What you do next can determine whether you spiral into guilt and self-doubt or face your actions, learn from your mistake and become a better nurse in the future.
THE SPIRAL OF DOOM
The initial shock or horror at having made a mistake may give way to disbelief, guilt, shame, fear, anger or all of the above. Those reactions are normal, but if the negative thoughts and feelings continue unabated for long after the incident, they can damage your career every bit as much as can an official reprimand.
Anxiety and self-recrimination are distracting, which puts you at greater risk of making other mistakes and can leave you burned out or even drive you to quit nursing. Navigating those feelings constructively after making a mistake is crucial to your mental health and your professional future.
After you’ve completed whatever medical and ethical steps may be required, it’s a good idea to take a short break to regroup. Talking to a trusted colleague about what happened and how you’re feeling can be invaluable and help you put the situation in perspective. Making mistakes is human, after all, and for some of us, so is the tendency to imagine that things are much worse than they actually are.
Sometimes, taking a few minutes to catch your breath may be all you need, particularly if the incident is already effectively resolved. If not, or if you find negative thoughts creeping back into your mind, it may be time to take a look at your self-talk.
TALKING TO YOURSELF
Most of us have “automatic” thoughts: a kind of spontaneous internal narration of our experiences and feelings. For some people, that narration is reassuring and compassionate. For others, such thoughts are frequently harsh and self-critical. If you have this kind of inner critic, times of stress may bring it out in force, repeating and reinforcing negative feelings in a way that can become self-sabotaging.
While you can’t necessarily control those thoughts, you can disagree with them and turn your internal monologue into a dialogue. By doing that, you can reshape your “self-talk” in a way that is more realistic, compassionate and fair, which will make it easier for you to move forward and deal with any problems or consequences you still have to face.
Here are some examples of common types of negative automatic thinking and how you can reframe those thoughts in more constructive ways:
Example: “Giving my patient the wrong medication is the worst thing I’ve ever done. I might as well quit before I’m fired.” (This type of thinking is called “catastrophizing” and is sure to make you feel worse!)
Corrective self-talk: “Giving the patient the wrong medication was a big mistake, but I know I’m a good nurse, I’ve never made that mistake before and I handled it correctly.” (This more compassionate self-talk considers the mistake in the context of a larger, successful career and is less likely to make you overreact and quit unnecessarily.)
Example: “I couldn’t do that procedure right — I’m no good at my job and I’m basically worthless.” (A steady diet of this type of all-or-nothing thinking would make anyone feel awful and put you at risk for depression.)
Corrective self-talk: “That procedure didn’t go the way I thought it would and I feel bad for my patient. Tomorrow, I’ll see about getting more training and I’ll be sure to ask for help next time.” (This self-talk acknowledges the error, but focuses on specific, constructive actions.)
Example: “Because of my error, my patient could have died. I’m sure their family will sue and I’ll lose my license.” (These fears might be realistic, but that doesn’t mean they will actually happen. Constantly assuming the worst possible outcome can leave you with overwhelming anxiety and lead to destructive coping behaviors such as substance abuse or frequently calling in sick to avoid going to work.)
Corrective self-talk: “Yes, the patient could have died, but he didn’t and he’s all right now. I made a serious mistake, but I know what to do differently going forward so I won’t make that mistake again.” (Instead of jumping to conclusions, this self-talk acknowledges responsibility while focusing on what you can do right in the future.)
If you find yourself struggling to come up with self-talk that is compassionate and reality-based, it can be helpful to write out the negative thoughts and ways you could reframe them. Again, consulting with a trusted colleague can be very helpful in finding a fairer, more realistic way to think about what happened. If you find yourself frequently stuck in negative thoughts or feelings about yourself or your work, meeting with a therapist can also help you change those patterns.
Taking these steps can make all the difference in transforming a mistake into an opportunity for growth, self-improvement and, ultimately, greater career satisfaction.
Mary Beth James, M.A., LMFT, is a licensed marriage and family therapist with a private practice in Pasadena. She specializes in working with nurses, doctors and other caregivers within the healthcare profession.
This article is from workingnurse.com.