Mississippi Nurse Edition 8 : Page 5
MiSSiSSippi BOARD OF NURSING a result of medical errors occurring in hospi- tals. In perspective, this would equate to the number of people who would die if a jumbo jet full of passengers crashed each day (Sil- verman, 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, train- ing, 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 acci- dent 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 asso- ciated with human error (Cronin & Mayer, 2008): • Human Error is an unintentional act that has the potential for causing an undesir- able 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. • Reckless Behavior is behavior that un- derstands that the risk is substantial and makes a conscious choice to disregard the unjustifiable risk. An example of this would be the nurse that knowingly ad- ministers potassium intravenously push instead of diluting the medication in a large fluid volume before administration. The culture of most health care institu- tions traditionally has been that human er- rors 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 po- tential 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 so- ciety, 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 report- ing systems’ errors and then be battered by a plaintiff’s attorney. An attempt to encour- age error reporting is a gigantic first step. The AmericanAssociationof Nurse Executives has adopted efforts to promote a culture of safety through error reporting. In addition, the In- stitute 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 commit continued on page 6 Reach Recruit Retain MiSSiSSip MiSSiSSip iSSiSSippi BOARD OF NURSING ippi BOARD OF NURSING a result of medical errors occurring in hospi- tals. In perspective, this would equate to the number of people who would die if a jumbo jet full of passengers crashed each day (Sil- verman, 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, train- ing, 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 acci- dent 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 asso- ciated with human error (Cronin & Mayer, 2008): • Human Error is an unintentional act that has the potential for causing an undesir- able 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. • Reckless Behavior is behavior that un- derstands that the risk is substantial and makes a conscious choice to disregard the unjustifiable risk. An example of this would be the nurse that knowingly ad- ministers potassium intravenously push instead of diluting the medication in a large fluid volume before administration. The culture of most health care institu- tions traditionally has been that human er- rors 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 po- tential 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 so- ciety, 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 report- ing systems’ errors and then be battered by a plaintiff’s attorney. An attempt to encour- age error reporting is a gigantic first step. The AmericanAssociationof Nurse Executives has adopted efforts to promote a culture of safety through error reporting. In addition, the In- stitute 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 commit continued on page 6 Reach Recruit Retain patient patient n exclusion the Duty to Report abandonment ar cr iSSippi BOARD OF NURSING a result of medical errors occurring in Sippi BOARD OF NURSING a result of medical errors occurring in hospi- tals. In perspective, this would equate to the number of people who would die if a jumbo jet full of passengers crashed each day (Sil- verman, 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, train- ing, 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 acci- dent 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 asso- ciated with human error (Cronin & Mayer, 2008): • Human Error is an unintentional act that has the potential for causing an undesir- able 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. • Reckless Behavior is behavior that un- derstands that the risk is substantial and makes a conscious choice to disregard the unjustifiable risk. An example of this would be the nurse that knowingly ad- ministers potassium intravenously push instead of diluting the medication in a large fluid volume before administration. The culture of most health care institu- tions traditionally has been that human er- rors 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 po- tential 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 so- ciety, 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 report- ing systems’ errors and then be battered by a plaintiff’s attorney. An attempt to encour- age error reporting is a gigantic first step. The AmericanAssociationof Nurse Executives has adopted efforts to promote a culture of safety through error reporting. In addition, the In- stitute 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 commit continued on page 6 Reach Recruit Retain patient n exclusion the Duty to Report abandonment ar cr Mailed Mailed to every nurse in Mississippi – over 50,000. The mississippi Board of Nursing JourNal to reserve advertising space contact victor horne vhorne@pcipublishing.com 1-800-561-4686 ext.114 our nursing journals are mailed directly to over 1.5 million nurses, healthcare professionals and educators nationwide. Arizona Arkansas The District of Columbia Indiana Kentucky Mississippi Montana Nebraska Nevada New Mexico North Carolina North Dakota Ohio Oregon South Carolina South Dakota StuNurse/Nationwide Tennessee Washington West Virginia Wyoming ThinkNurse.com SUMMER 2010 5 MiSSiSSippi BOARD OF NURSING vol.2 no.4 june 2010 The New Paradigm: Just Culture Pseudophedrine… it’s Not Just for Colds SUMMER 2010 1
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