Errors as Opportunities

Learning from mistakes

As a nurse for many years, I have learned it is best to take the extra time to check and double check things. I have seen many errors over the years, because I, or someone else, was in a rush, and a pause to clarify or check details was omitted. It is easy to assume the intent of an order is understood, even if it seems odd or incorrect. It is easy to miss a discrepancy in dosing, because time is not taken to look it up. Our organization has a “high reliability” campaign in place, and every employee is required to attend error prevention training. The tools learned there are becoming part of the regular vocabulary in emails, presentations and even face-to-face discussions: team member checking, clarifying questions, ARCC, STAR and several others. These tools go hand in hand with the leadership style of the Information age, because they create horizontal relationships and encourage everyone to ask questions, make suggestions, and voice safety concerns, regardless of their “rank” in the organization. It does not happen overnight, but changes are apparent!

Responding to conflict and errors

Our medical director is a leader who handles conflicts and errors well. He is slow to judge, gathers information, and likes to take the “30,000 foot view” when considering situations. He is not reactive, but instead he gives thoughtful consideration and asks for input from others before making decisions. When a reportable event occurred a while ago, his response was to talk with those involved, review the chart, and maintain a calm demeanor. He also demonstrated great concern for the staff involved and their well-being, speaking to all in a supportive manner and avoiding blame. This approach is a stark contrast to another leader I worked with in my early years as a nurse. This leader’s approach was more hierarchical and controlling. Her tone was condescending, and she had a negative attitude towards the staff. She was more likely to place blame on people, thus, most nurses were not forthcoming when an error was made. Ultimately, the situation put patient safety at risk, because potential system problems could not be identified and remedied when people were afraid to report errors.

As a CN, I strive to connect with everyone I work with. Sometimes I worry about the time used chatting with nurses, especially if it is non-work related, but it is ultimately time well spent. I know people more personally and have a sense of who they are. I find a nurse is more likely to hear me and trust what I have to say, when they know me. I can relay safety information as a helpful tip or something nurses needs to know rather than an edict they must follow, and they are not only receptive, but they perceive the interaction as supportive and helpful rather than commanding. I am always open to suggestions or ideas for improving safety, and I try to share them with others as well.

Insights from Atul Gawande

Many of the ideas Gawande discussed in his TEDx talk go right along with the high reliability work my organization is doing. Standardizing certain elements of care to ensure all critical steps are completed, taking time to think about the task at hand, and respecting the role and value of each team member’s contribution are examples of such work. I appreciated the idea of a “pause” before proceeding. In a time when technology has increased the pace of work and distractions are plentiful, taking a few moments to focus on the task at hand is essential. Providing safe care is critical to improving the quality of care, and ultimately increases the value as well.

As a non-profit organization, cost effective care is important, although perhaps for different reasons than a for-profit organization might give. In order to stay in business and offer care to all, regardless of ability to pay, the institution must closely manage the budget. The difficulty is determining what will result in cost effective care. For example, it might be more expensive to use a particular dressing on a central line, but if it does a better job of protecting the site and preventing a costly blood stream infection, the money is well spent. For these reasons, patient outcomes should also be measured, and strategies used to improve unacceptable rates. Ultimately, this approach can result in decreased costs as well as improved patient care.

Patient satisfaction should also be measured. While it can seem superfluous at times, how the patient feels about the care received holds a great deal of influence and cannot be dismissed. “Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It affects the timely, efficient, and patient-centered delivery of quality health care. Patient satisfaction is thus a proxy but a very effective indicator to measure the success of doctors and hospitals (Prakash, 2010, p. 151).

Porter-O’Grady and Malloch (2015) discuss the need to eliminate things that do not contribute to good outcomes. As a QI coordinator, I wholeheartedly ascribe to the idea of efficiency and making the workload lighter in order to focus on the essentials. If a service or task is not adding value to the care of the patient, it deserves closer scrutiny and possible elimination. The value a service or task adds to the patient experience and outcome is worth measuring in order to decide which things stay and what is eliminated.

Addressing Interruptions

As technology continues to advance, there are more ways than ever to find ourselves distracted. Social media, cell phones, and email are always present and demanding our attention, but as a nurse, there is a multitude of additional interruptions to our focus. Alarms, patient needs, coworkers with questions, and new orders are a few, and the list goes on indefinitely. This problem is particularly worrisome, because a study cited by the Patient Safety Network suggests there is a 12.7% increase in the risk for a medication error with each interruption while the med is being prepared and administered.

There are many ways to tackle the issue of interruptions, and multiple aspects of care to consider. Our organization has begun looking at the issue of alarm fatigue, and changes are occurring in the default settings of our monitors. In our unit, a project is being considered to determine whether the noise level is an issue. As a CN, I find it difficult to get through lunch without multiple phone calls, and the number of interruptions as I gather report information at the end of the shift continues to grow. I try to model not interrupting if I arrive at a patient room for report and see the nurse in the midst of a complex tubing change. I move on to the next room and return to that nurse later. I have also coached nurses how to address families who are talkative, or have many requests, in order to decrease interruptions. For example, “I need to get these medications ready and give them to Billy, so I will talk with you more when I am done” or “I need to check on my other patient, so I will be out of the room for a while. I will be back at 2:00, and we can give Sarah her bath then.” As a QI coordinator, this topic would be a good one to address, as the problem is huge, and the impact directly affects patient outcomes. This idea is definitely something I need to consider.

Handling Mistakes in a Just Culture 

As a nurse in the workforce for over 30 years, I know all too well how easy it is to make an error. I also know the guilt and stress produced by errors. Rarely do errors occur due to maliciousness or neglect, but rather they usually seem to be the result of a memory lapse, inattention, misunderstanding or some other understandable, yet unfortunate, situation. I try to have a very supportive response when an error is made, because I know most nurses are devastated when something happens.

I am thankful the organization for which I work believes strongly in a just culture. There is concern for the patient, determination to investigate and avoid similar events in the future, and support for the person who made the error. Of course there may be consequences if risky or negligent behavior is involved, but overall, there is not a rush to judgement or blame, and the entire situation is approached as a system issue as the analysis begins.

The state of Missouri has recommendations related to patient safety; however, there is no requirement for mandatory reporting. As a high reliability organization, all employees are encouraged to report safety issues of any type through an internal reporting system, including “near miss” events in which no harm reached the patient. Positive feedback is given for such reporting including “great catch” awards, which are reported in the employee newsletter. While the increase in reporting requires an increase in follow-up activity, the outcome is such that problems are identified and addressed. This focus on safety and preventing errors is definitely a step in the right direction.

References

Beyea, S. (2014). Interruptions and distractions in health care: Improved safety with mindfulness. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-health-care-improved-safety-with-mindfulness

Boynton, B. (Director). (2012). Interruption awareness: A nursing minute for patient safety[Video file]. Retrieved from https://www.youtube.com/watch?v=PGK9_CkhRNw&t=311s

Extension Healthcare. (2016). Clinical Interruptions. Retrieved from http://www.extensionhealthcare.com/industry-challenges/alarm-management/clinical-interruptions/

MISSOURI –Public and Private PolicyMedical Errors and Patient Safety. (n.d.). Retrieved from http://qups.org/med_errors.php?c=individual_state&s=26&t=all

Porter-O'Grady, T., & Malloch, K. (2015). Quantum leadership: Building better partnerships for sustainable health (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Prakash, B. (2010). Patient satisfaction. Journal of Cutaneous and Aesthetic Surgery, 3(3), 151-155. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047732/

TEDx Talks (Director). (2012). Atul Gawande: How do we heal medicine? [Video file]. Retrieved from https://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine