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Exam #2

Nursing 477

Jennifer L. Fannin

April 22, 2010

1. What was the underlying cause of this incident?

This incident was caused by multiple underlying issues. The first and foremost cause is multiple systems issues or environmental issues. In this case the drips that were being used were packaged in nearly identically packaging and stored in the same location in the medication cart. There was also not a process in place to verify that the right drip was being used for the correct patient. The second environmental concern is the lack of supplies such as the appropriate size blood pressure cuff and the delivery issues of medication from the pharmacy. The other factor that may have been a partial cause is the staffing issues. As noted in the readings it is important to understand that errors are not caused by one single factor or one single individual. Traditionally the focus has been on the individuals error and not the system that was in place at the time of the error that may have played a role in contributing to the error. Benner (2002) states, A systems approach is the established structural and functional ways of operating and interacting designed into an organizational system, which includes the internal and external forces on the organizational system. The practice responsibility refers to the socially embedded knowledge, notions of good and skill lodged in a healthcare team. If this problem is focused on from the systems approach there are a large number of error-reduction strategies that could be instituted to prevent this error in the future. The first line of defense would be to attempt to error proof the process. This has been done in other industries such as the airline industry where Firewalls are created around procedures and task that are high risk. In this case the organization could attempt to rethink their supply carts and not place look-alike, sound-alike drugs in the same location. An automated medication dispensing system may have prevented this error if the person could only choose from medications that had been ordered on that patient. It would have also been

beneficial for a second line of defense to have been in place such as a second check by another RN to verify the right order, right medication and right patient.

2. What factors can be contributing to Ethels reluctance to report the incident?

The strongest factor that is contributing to Ethels reluctance to report this incident is the social barriers that are embedded in the system. Because Ethel is an experienced nurse it would be an embarrassment to her to admit to co-workers that an error was made. Ethel is probably not too positive about a nurse that is relatively new to the unit asking her to report a mistake. As stated by Cannon (2005), people have an instinctive tendency to deny, distort, ignore or disassociate themselves from their own failures. It is obviously the culture of the unit to dismiss this type of error as minimal considering that Ethel mentions that lots of people have grabbed the wrong bag before. To avoid this type of culture the organization must be willing to put constructive incentives in place to identify these systems failures and to speak up and not have a punitive system in place. The leader of this unit must create a culture in which staff feels empowered and safe to speak up. The best way for this to occur is for the leader of the unit to model this behavior by coming up with new ideas that are inviting of constructive criticism and show their willingness to learn from their mistakes. Leader modeling will also help to communicate this new idea of using failure to learn because the leader must first communicate the expected behavior to his/her staff. The leader of the unit must also support the staff with the time to analyze the failure and to create possible solutions to prevent it from reoccurring. A positive way of during this is creating work groups of staff who have identified an issue.

3. What should the nurse manager do in response to Ethels comments to Lucy?

The nurse manager must address the comments that were made. She needs to be willing to coach Lucy on how to have a crucial conversation with Ethel regarding her position in reporting this error. If Lucy is uncomfortable having this conversation with Ethel it is the nurse managers responsibility to address this issue with Ethel. Even though addressing this issue with Ethel may create negative conflict it also has the opportunity to promote a positive change to increase patient safety in the unit and the organization. This is a process oriented conflict which is detrimental to the performance of a group, in this case the nursing team. The high emotions that are associated with failure and mistakes tend to lead team members to loose sight of their overall goal, patient safety. If this conflict is addressed and resolved the studies show that there should in turn be a positive effect in the long run on performance and satisfaction within the nursing unit.
4. What strategies can the nurse manager implement to improve error reporting on the unit?

As previously mentioned the nurse manager must create a positive environment in which the staff feel comfortable, safe and supported in reporting errors. The nurse manager must communicate this change in culture to the staff through a variety of modalities to include staff meetings (direct verbal communication), and learning activities such as PowerPoint presentations. A blameless reporting system should be put in place that allows the staff to report errors that are found. Within this system there should be a process where the nurses that were involved receive feedback on the outcome

such as information on how an organizational system is being evaluated based on the information that was reported. The nurse manager should involve her staff in creating this error reporting process to assist with staff by-in and help them feel as though they are participants in this process and not being forced into something new that is uncomfortable for them. The nurse manager must also educate the staff on the process in which an organization learns from failure. This education should include teaching the staff the process of learning from failures which includes how to identify failures even though they may seem small and insignificant at the time, analyzing failure and deliberate experimentation. Recognition of the small failures and system modification can prevent catastrophic failures in the future. The unit leadership should put meaningful incentives in place to promote the reporting of errors on the unit. The manager of the unit must also prepare him/ herself to deal with the high level of emotions that are involved with failures. This will take a high level of interpersonal skills, so therefore she must be willing to evaluate him/herself and determine if he or she themselves will need coaching from an outside source to support her staff in the initiation of this process. In summary this will be a gradual period of adjustment in order to change the culture of this unit to one in which mistakes or failures are openly reported and discussed in a positive way to help create an environment in which patient safety is the highest priority. The leader of the unit must take this opportunity to build a structure that will support the staff in reporting these small failures which have not caused harmed to patients to prevent larger failure which could have irreversible effects.

Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K. & Jamison, D. (2002). Individual, practice, and system causes of errors in nursing. Journal of Nursing Administration, 32(10), 509-523.

Cannon, M. D., & Edmondson, A. C. (2005). Failing to learn and learning to fail (intelligently): How great organizations put failure to work to innovate and improve. Long Range Planning, 38(3), 299-319.

Gurses, A. P., Carayon, P., & Wall, M. (2009). Impact of performance obstacles on intensive care nurses workload, perceived quality and safety of care, and quality of working life. Health Services Research, 44(2, Pt 1), 422-443.

Jehn, K. A. (1997). A qualitative analysis of conflict types and dimensions in organizational groups. Administrative Science Quarterly, 42(3), 530-557.