If a mistake harms a patient, what happens next in your ED?
If a mistake harms a patient, what happens next in your ED?
Don't take a punitive approach toward your nurses
About two years ago, a psychiatric patient at Providence St. Vincent Medical Center in Portland, OR, hung herself with the belt of her robe after being in the ED for an extended period. The patient survived and had no permanent adverse effects, but the way the incident was handled ultimately made the ED safer.
First, instead of blaming or punishing the ED nurses involved in caring for the patient, a debriefing was done to give them support. "Our ED management team approached this event in a very scientific and nonjudgmental way," recalls Wayne Schmedel, RN, an ED nurse at Providence St. Vincent. "We focused on a systems analysis, rather than on specific staff or personalities."
The ED's root-cause analysis revealed inconsistencies in the way potentially suicidal patients were assessed. This "spoke loud and clear that although errors can happen, it is in the best interest of each of our current patients, and even more so with our future patients, that as a team we can learn from our errors," he says.
A recent Sentinel Event Alert from The Joint Commission recommends a policy of "transparency" that permits staff to report near misses and mistakes without fear of reprisal. (Editor's note: To access the complete Alert, go to www.jointcommission.org. Under "Sentinel Event," click on "Sentinel Event Alert" and then "Issue 43: Leadership committed to safety.")
If you take a punitive approach, ED nurses will be less likely to report an incident, says Mary J. Ross, RN, BSN, CEN, a senior partner at the Emergency Medical and Trauma Center at Methodist Hospital in Indianapolis. Methodist's ED holds a "Safe Passage" monthly meeting on patient safety attended by nurses, physicians, residents, managers, and directors. "If an error occurs, we try and have the nurse who made it present it to the group. The nurse presenting often comes away feeling very supported," she says.
When an error is presented, a "first story/second story format" is used. "The 'first story' is the actual incident," says Ross. For example, an ED nurse recently gave the wrong antibiotic to an admitted patient with pneumonia, even though the correct medication was clearly written on the admission order sheet.
The "second story" is all the facts and background information that were not included in the incident report. "This is obtained by interviewing the nurse or nurses involved in the error. You focus on any and all things that may have led to the error, including staffing, experience, or time of day," says Ross. For the above incident, these additional facts were considered:
• An experienced charge nurse with more than 20 years of experience in the ED was involved. "The nurse who made this mistake was accustomed to always giving vancomycin for pneumonia," says Ross. "This was the type of mistake only a very experienced nurse would have made."
• The area was extremely busy. Three ED nurses were covering a 13-bed area with five patients in the hallway waiting for treatment on the noncritical care side. The third nurse was pulled to perform a sexual assault exam, so the charge nurse took over her assignment.
As part of the ED nurse's presentation on this error, an article on "inattentional blindness" from an Institute for Safe Medication Practices publication was reviewed. (Editor's note: To read the article, go to www.ismp.org. Click on "Newsletters," "Acute Care Edition," and "Past Issues." Under the 2009 heading, click on "February 26" and then scroll down to "Inattentional blindness: What captures your attention?")
"This showed everyone that regardless of experience, anyone can make an error. It made the nurse feel a lot better," says Ross. "One recommendation that came out of this was to encourage the nurse to scan the orders to pharmacy and have pharmacy prepare all admission meds. A second set of eyes is always good."
Debbie Stubblefield, RN, an ED nurse at Baptist Memorial Hospital — Desoto in Southhaven, MS, says ED nurses must "shift from the thought process of 'telling on a team member' to 'that would be a mistake anyone could make unless we change the way we do things.' A clinical error is an opportunity to improve our processes and outcomes, as opposed to assigning blame."
Sources
For more information on a nonpunitive approach to errors in the ED, contact:
- Mary J. Ross, RN, BSN, CEN, Emergency Medical and Trauma Center, Methodist Hospital, Indianapolis. E-mail: [email protected].
- Wayne Schmedel, RN, Emergency Department, Providence St. Vincent Medical Center, Portland, OR. E-mail: [email protected].
- Debbie Stubblefield, RN, Baptist Memorial Hospital — Desoto, Southaven, MS. Phone: (662) 772-3275. E-mail: [email protected].
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