Mississippi Nurse Edition 8 : Page 4

MiSSiSSippi BOARD OF NURSING ANN RIckS, RN, BSN Director of iNvESTigaTioNS THE NEW PARADIGM: Just Culture A first impression when we hear a description of a nurse in her late forties, wife and mother of three, who has practiced nursing in an intensive care unit (ICU) for twenty-five years is quite different from what we envision as a convicted criminal or felon. In the culture of nursing as we know it, the potential for each of us falling into the same description as the nurse above is a potential reality. The nurse was convicted twice of manslaughter in the medication death of a three-month old child. The case is headed before the Supreme Court for a final appeal (Dekker, 2007). The story begins with the admission of a child to the ICU with a bout of seizures that were uncontrolled by routine anti-epileptic medication. A lidocaine-based medication was administered intravenously and the child was eventually sent home after the seizures subsided. Two days later the child was readmitted to the ICU for a new onset of seizures now lasting up to five minutes in length. On this day, there were few patients in the unit when the nurse mixed a lidocaine drip for the child. The lidocaine medication was located in the drug room and the nurse chose between two different bottles of lidocaine with similar lettering and coloring on the packages. One package read 20 milligrams per milliliter (20mg/ml) and the other 200 mg/ml. Having chosen the bottle with 200mg/ml by mistake, the nurse inadvertently prepared an infusion of lidocaine which was ten times greater that the intended dosage. After the medication was initiated intravenously, the seizures became constant. Unbeknownst to the medical team, the baby was receiving a toxic level of lidocaine. To complicate matters, seizure activity was a side effect of lidocaine toxicity. Not knowing the error in the intravenous dosage that was 4 SUMMER 2010 Looking back over the course of events that transpired prior to the error, there were numerous systems’ failures that contributed to the event which were not taken into consid- eration during the nurse’s trial. There was a poorly written physician’s order that was mys- teriously missing. Another error of chance, the two bottles of lidocaine which had basi- cally identical packaging for differing dosages of the medication was not considered. The fact the facility generally cared for adult pa- tients and not children posed another oppor- tunity for error because neither the nurses nor the ICU were specially equipped to prepare medications and treat babies. The culture of the hospital, or better understood as, “the way things were generally done” at the hospital, contributed to the error, but was not consid- ered in the plight of the nurse. The nurse was in a position known as being at the “sharp end” (Brous, 2008, p. 5). She was held accountable for her human error that had no malicious intent. In her honesty and effort infusing, the treating physician ordered even more lidocaine boluses. The seizures worsened and ultimately, the child died. An autopsy revealed death by lidocaine poisoning. The nurse, in an attempt to be forthcoming and honest, came forward and notified superiors of her calculation error. News of the error leaked outside of the hospital and the nurse was ultimately arrested on a charge of manslaughter. to do the right thing, she divulged her error and became a convicted criminal. Of all involved, the physician with the poorly written order, the drug company that produced confusing label- ing, the physician who kept ordering lidocaine boluses when the child’s seizures would not cease, none received even a reprimand. The culture of the hospital, the legal arena and the patient’s family demanded accountability and restitution at a huge price. In this case, human error was deemed a criminal act, but was it? In 2000, the Institute of Medicine (IOM) published a landmark report To Err is Human: Building a Safer Health System. The IOMreported that as many as 98,000 people die each year as

The New Paradigm: Just Culture

Ann Ricks

A first impression when we hear a description of a nurse in her late forties, wife and mother of three, who has practiced nursing in an intensive care unit (ICU) for twenty-five years is quite different from what we envision as a convicted criminal or felon. In the culture of nursing as we know it, the potential for each of us falling into the same description as the nurse above is a potential reality. The nurse was convicted twice of manslaughter in the medication death of a three-month old child. The case is headed before the Supreme Court for a final appeal (Dekker, 2007). The story begins with the admission of a child to the ICU with a bout of seizures that were uncontrolled by routine anti-epileptic medication. A lidocaine-based medication was administered intravenously and the child was eventually sent home after the seizures subsided. Two days later the child was readmitted to the ICU for a new onset of seizures now lasting up to five minutes in length. On this day, there were few patients in the unit when the nurse mixed a lidocaine drip for the child. The lidocaine medication was located in the drug room and the nurse chose between two different bottles of lidocaine with similar lettering and coloring on the packages.One package read 20 milligrams per milliliter (20mg/ml) and the other 200 mg/ml. Having chosen the bottle with 200mg/ml by mistake, the nurse inadvertently prepared an infusion of lidocaine which was ten times greater that the intended dosage. After the medication was initiated intravenously, the seizures became constant. Unbeknownst to the medical team, the baby was receiving a toxic level of lidocaineTo complicate matters, seizure activity was a side effect of lidocaine toxicity. Not knowing the error in the intravenous dosage that was infusing, the treating physician ordered even more lidocaine boluses. The seizures worsened and ultimately, the child died. An autopsy revealed death by lidocaine poisoning. The nurse, in an attempt to be forthcoming and honest, came forward and notified superiors of her calculation error. News of the error leaked outside of the hospital and the nurse was ultimately arrested on a charge of manslaughter. Looking back over the course of events that transpired prior to the error, there were numerous systems’ failures that contributed to the event which were not taken into consideration during the nurse’s trial. There was a poorly written physician’s order that was mysteriously missing. Another error of chance, the two bottles of lidocaine which had basically identical packaging for differing dosages of the medication was not considered. The fact the facility generally cared for adult patients and not children posed another opportunity for error because neither the nurses nor the ICU were specially equipped to prepare medications and treat babies. The culture of the hospital, or better understood as, “the way things were generally done” at the hospital, contributed to the error, but was not considered in the plight of the nurse. The nurse was in a position known as being at the “sharp end” (Brous, 2008, p. 5). She was held accountable for her human error that had no malicious intent. In her honesty and effort to do the right thing, she divulged her error and became a convicted criminal. Of all involved, the physician with the poorly written order, the drug company that produced confusing labeling, the physician who kept ordering lidocaine boluses when the child’s seizures would not cease, none received even a reprimand. The culture of the hospital, the legal arena and the patient’s family demanded accountability and restitution at a huge price. In this case, human error was deemed a criminal act, but was it? In 2000, the Institute of Medicine (IOM) published a landmark report To Err is Human: Building a Safer Health System. The IOM reported that as many as 98,000 people die each year asa result of medical errors occurring in hospitals. In perspective, this would equate to the number of people who would die if a jumbo jet full of passengers crashed each day (Silverman,2008) . The numbers are staggering.We can do better in terms of safety. There is no room for doubt involving changes that can be made in terms of education, training, better equipment, increased staff and better leadership. The fact remains, human error and accidents are going to occur. It is not possible to anticipate each error or accident that can happen in regards to human behavior including all variables involving the medical team, the health care facility as well as the patient. There are three types of behavior associated with human error (Cronin & Mayer, 2008) : • Human Error is an unintentional act that has the potential for causing an undesirable outcome. An example would be to accidentally omit an order for insulin. • At-Risk Behavior is a result of unsafe habits involving conscious deviation from known rules and expectations.For example, a nurse who knows that a post-surgical patient’s vital signs need to be assessed every fifteen minutes per the hospital policy, but consciously decides to check them only every sixty minutes.to disregard the unjustifiable risk. An example of this would be the nurse that knowingly administers potassium intravenously push instead of diluting the medication in a large fluid volume before administration.The culture of most health care institutions traditionally has been that human errors made by the front line staff are addressed by punishment with disciplinary action or maybe even termination from employment.Rarely does the culture look at the overall system. This response to errors does little for patient safety. Addressing errors at “the blunt end,” (Brous, 2008) has the greatest potential for making changes to prevent further occurrences of the same type of errors. A change in the culture of institutional environments will require a paradigm shift to improve patient safety. Today’s culture is all about placing blame. We have all heard the comments “she screwed up” or “she needs discipline.” To change the culture, a more positive approach needs to occur in the direction of statements such as, “what went wrong” and “how do we prevent it from happening again.” Blame needs to take a back seat to determining what can be done differently next time to keep the same type of offense from happening again(Brous, 2008). The IOM determined that the majority of medical errors have been proven not to be the fault of people, but rather systems, processes and conditions.Considering our litigious society, disclosing systems’ errors can, in itself, be a difficult prospective for any health care institution. Health care institutions do not want to be forthcoming by publicly reporting systems’ errors and then be battered by a plaintiff’s attorney. An attempt to encourage error reporting is a gigantic first step. The American Association of Nurse Executives has adopted efforts to promote a culture of safety through error reporting. In addition, the Institute of Healthcare Improvement strategic plan is to provide recommendations to reward reporting of errors and share trends of reports (Scott-Cawiezell & Vogelsmeier, 2007).An attempt to disclose medical error by providing a supportive culture is a tremendous undertaking. The missing voice in the reporting is that of the front line staff.Consider the example of the nurse noted above; the nurse was on the front lines, the nurse reported and was subsequently made a criminal. In a just culture, this would not happen. The ideal situation would have been for the nurse to report her error and assume accountability for her mistakes. Just culture does not relinquish accountability but expects accountability and responsibility for actions while the facility administration takes the necessary steps to ensure that such an error never happens again. In our society of blame and restitution, people who have accidents and commithuman error are treated badly. Expecting front line individuals to come forth is asking them to risk their livelihood and freedom as a citizen. There are a vast number of errors that occur on a daily basis that are not reported for fear of retaliation from patient families, peers and managers. Failure to report human error and accidents hinders the opportunity to make our health care safer. A just culture, is one where individuals receive positive attention for safety conscious behaviors including reporting. “Individuals areonly blamed if there is a specific evidence of recklessness or negligence” (Armitage, 2009 p.198). Without a just culture, progress towards safe health care is hindered. In a just culture, a human error without intention or malice is considered an opportunity for learning and does not lead to disciplinary action (Marks, 2001). Thus, employees are provided the safe environment in which to come forward and not fear retribution. As is, the severity of the outcome plays a large role in what happens to the individual that errs. Culpability is and has been strongly influenced by our legal system. The barriers to developing a just culture include the fear of potential litigation and other legal standards for individuals. However, in spite of these barriers, there are nurse leaders and administrators that realize the importance a just culture can have on patient safety. The challenge for nursing leaders is to determine between human error and reckless behavior. These two types of behavior are at different ends of the spectrum when determining accountability.In a just culture, human error would not warrant disciplinary action.On the contrary, reckless behavior would not be tolerated and would warrant disciplinary action. At-riskbehavior, the third type of behavior would be reviewed on an individual basis and the merits of each scenario would be weighed. At-risk behavior is often influenced by peer pressure or occasionallybyconflictingorganizational policies. An example of at-risk behaviorWould be akin to someone breaking the speed limit while driving. Everyone has done it from time to time, without any intention of posing a threat or harm to a fellow driver. At-risk behaviors would warrant disciplinary action when offenses are repeatedly committed after the individual has been counseled and warned (Cronin & Mayer, 2008). Learning to decipher the difference between human error and reckless behavior will provoke much thought and controversy. Asking questions such as, • Did the nurse choose the behavior? • Did the nurse see the risk? • Did the nurse intend the actions? Can help a nurse leader decipher between human error and reckless behavior (NM Nurse, 2008). In conclusion, a just culture is a pathway to improve patient safety by balancing accountability with safety (Dekkar, 2007). Removing the barriers of legal implications can prove to be a huge obstacle, but dedicated nurse leaders and administrators that understand the implications and rewards of its implementation are forging ahead. Just culture benefits all, including the public and the victims. Health care professionals have the duty and responsibility to disclose facts, be honest and to apologize for committing a mistake. Human error is going to occur. How a health care institution decides to deal with errors can have lasting implications for patient safety.When mistakes happen, the individual and the system need to be managed, as it has been noted,Disclosure of medical errors has proven in history to bring about changes in healthcare to promote safer care. An example of this would be the death of a healthcare reporter in 1994 from a chemotherapy overdose. Her death occurred at Harvard’s Cancer Institute and it brought about a new focus on medication errors and how prescriptions are written, possibly initiating the need for computerized prescribing. Another example would be the death of a 17-year-old girl, who died at Duke University after receiving a heart-lung transplant and ultimately receiving the wrong blood type. The error associated with her death brought about a new focus on errors in transplantation and the enforcement of strict, high, reliability protocols for communicating critical data (Wachter, 2008).human error is often the result of systems’ issues. “Being blame-free is not the same as beingaccountability- free” (Luk, 2008). Establishing a just culture will require time and energy of professionals, the community and the legal arena. The initial approach will be educating stakeholders in the concept of just culture and what implications it can have for the health care industry. The next step will include follow-up by building trust within health care organizations, so that employees will feel secure in admitting and reporting errors. Removing the threat of legal ramifications, in this writer’s view, will be a monumental challenge.The snowball has been rolling out of control for many years by holding nurses and other health care workers unjustly accountable for human error and accidents. Nursing leaders must strive within our health care arenas toward balancing safety and accountability. Removing the “placing of blame” is counterculture for most health care institutions. Nurse leaders need to work harderat evaluating and changing the cultures in health care to encourage reporting. Human error and accidents need to be considered a learning opportunity and not a call for discipline and retribution.

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