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Tess:So we're all back again and it's Tess Judge-Ellis
Rebecca:and Rebecca Porter
Andy:and Andy Whitters
Tess:and welcome to Friends of Flo and today we're very excited to be able to have an expert in the field of medication errors and ethical considerations that's our very own Rebecca Porter.
Rebecca:I wrote this paper several years ago and I think it's still relevant and I think we're going to have it posted. I was invited to write this paper and it was really interesting and rather frightening to get into the literature about it. I was looking at it through a lens of ethics and it was really interesting to get into the literature because I had all these assumptions about it doesn't happen very often and nobody talks about it when it happens. And how are we supposed to act when a medication error occurs or in your midst. And when you consider I don't know what you guys consider to be a medication error.
Tess:Well what I liked in your paper was you first defined an error. You know they're unintentional acts that may or may not result in harm that can be judged to be erroneous by practical and reasonable standards. And I think you guys picked that as you say in your paper because it allows for discussion of ambiguous medical errors, right? Or medication administration errors or MAE's that would be near misses or missed doses that resulted in no obvious harm to the patient. So that really broadened the discussion because you know oftentimes that is the case is you do a med error. But you know it's not really going to hurt the patient...
Rebecca:Right and so you never say anything. Or you miss an antibiotic dose, but oh well.
Tess:Exactly
Rebecca:You know you feel badly for a little while. And usually no one finds out until somebody orders drug levels or antibiotic levels and then it's all wonky and everybody gets all excited and then...
Tess:Or not even that serious of stuff. You know what I'm saying like anytime that something makes a mistake. What I like about your paper is because it's we talked about this earlier. Nursing is the last line before the patient. But yet there's so many other aspects of what goes into an error when you broaden the definition of medication errors then that brings in a conversation about the ethics and trustworthiness and honesty. And so that was a big part of your piece is what does it mean to have trust and what does it mean to be trustworthy. So I liked that about your piece. So I guess talk about I guess that's a place to start is talk about trustworthiness and the code of ethics and honesty that we have.
Rebecca:So right when we talk about the ethics of making a mistake you know we're looking at the virtues of being a nurse. Virtue ethics...and we think about things like trustworthiness. We think about being accountable and we think about responsibility and taking responsibility. Being accountable for what we do is one of the most important professional expectations of being a registered nurse and that includes PCR and aged midwives. The whole continuum of nursing and accountability means that I have a judgment to do the right thing. So we were talking earlier about before we started recording today about near misses or our own professional judgment and is it recognized and do we speak up and you have a story Tess about...
Tess:Oh back when I was first a nurse in the emergency department. So I was a nursing emergency department and this patient was in need in need of potassium replacement. And it was very urgent and there was the physician wanted me to push I.V. potassium I don't know that dose, but I knew enough to say I don't think that's right to push this and I'm not sure I'm comfortable with that. And then the doctors there were two physicians and somebody else I didn't even recognize in the room and of course the patient and me. And the doctors both said"no, no, no, that's OK you can do this" And so as I started to do it this person who was unnamed in the room says with a very authoritative calm voice said,"if you do that be prepared for the patient to have an arrest if you do that. That person is going to die" basically validated everything I had been saying. It ended up that that was the anesthesiologist. And so we got into the discussion was the nurse being right there with the patient.
Rebecca:Right, and so when you look at that through the lens of the virtues of responsibility and accountability what it is doing is saying you have to speak up and you have to be confident in what you're doing. We nurses are the last point of safety between the patient and everything else that happens to them. That will get into trustworthiness in just a minute. But one thing that I think is really important about accountability and taking responsibility is getting away in medical or medication errors. However broadly we define it, is getting away from that name blame and shame environment that we have a responsibility a moral responsibility and I think legal responsibility to create a working environment where people are not named, blamed and shamed. So it's a place where are you supported when a near miss happens.
Tess:Yeah it's the culture and the leadership culture of the...your papers. Excellent. And it is.
Andy:You spelled it out in the conclusions where you say it's an opportunity to exercise kindness I believe and I'm paraphrasing, but that is a cultural thing that I think nurses tend to beat each other up when errors do happen. And to err is human.
Tess:Well the first sentence of the article,"errors or mistakes are part of the human experience" period. I mean this is.
Andy:And we should be able to support each other and be like yeah we made a mistake. Let's move on.
Rebecca:Nobody comes to work intending to do something wrong. And this could happen to any one of us and kindness showing shame, man oh man. How are you doing. And instead of getting into the gossiping and blaming and shaming. But sometimes when these mistakes happen where we're so busy that we don't even realize what's happened until we get home from work and are reflecting on what happened. And you go back and disclose and to whom do you disclose. And it should not be, well I'm not going to talk about it ever and I'm not going to fill out an incident report because things have a way of surfacing.
Andy:So let's talk about that...
Tess:Because I think there were questions too that had been sent in about who do you report to, how do you do this and do you fill out the incident report and do you document that.
Rebecca:Why would you not fill out an incident report?
Andy:I would imagine for fear.
Tess:Exactly
Rebecca:When you look at why do medication errors happen so when you as a nurse are giving a medication. Here's an example: when you are giving a medication you're going to make room you're picking up and you go to the patient's bedside and let's say the bedside people are visiting and talking you don't know who everybody is in your room. When you give them medication you give it to the right drug to the right patient at the right time and are steps involved in all of those, but the bedside is really chaotic. And there is a whole bunch of people in there visiting. So do you actually stop and say Mr. So-and-so could I see your name band. Could everybody stop talking for just a minute. I want to give him medication. Or do you just sort of slip it to them and say here's your med and run out of the room and if you're a nurse practitioner writing a prescription for a patient do you actually print it out in hand printing for them away from distractions and say this is this medication. This is how you take it and make sure that they can say that back. And we're relying on technology so much and there's room for errors there.
Andy:Well not everybody has a name band. Not everybody has the ability to confirm their identity. So think about a dementia units think about long term care facilities skilled units offices dialysis units where you're relying on family members you're relying on other other nursing staff to identify patients where that identification that technology is not applicable in those situations.
Rebecca:I though name bands, yeah in a nursing home you know what happens when a new registered nurse comes on and doesn't know everybody and you have dementia. So what are the standards of that place what's protecting you as a nurse legally protecting you to make sure that this is the right person with the right drug at the right time. So those are things you think about it. And there's so many factors that go into making that error.
Tess:You talk about that in the paper is that even though it's the nurse's accountability at the very end. Right at the patient point of delivery of medication. You mentioned that there are lots of system factors that play a part in it. Your article talks about even and specifically in the ICU the poor lighting, the physical environment, the alarms, the distracted conversation. Then the communication is it a verbal order, was it written down, was it actually entered in the computer and then talk again about leadership issues. Who's responsible. Lack of support...
Rebecca:Not enough nurses
Tess:Yes not enough nurses. And then the social cultural milieu. So the communication collaboration issues, especially residents...
Rebecca:What if person you're working with is really a bully and really intimidating. I remember my very first job. I was so afraid the very first time I gave a medication without an instructor around hovering over my shoulder. I was terrified. And the nurse manager on the unit was now I know would label her as really a serious bully and she would stand over and yell at me and demean me and berate me for being slow and methodical. So what's that environment like, what is the leadership like, particularly when you're new.
Tess:Thinking about this how do we come up with solutions for our own, I think you called it agency...
Rebecca:Our own moral agency
Tess:And the professional moral agency in a morally safe environment and what's our responsibility for that.
Rebecca:We have to create that and it doesn't just come from leadership. It starts at the bedside and being responsible and accountable to your patient and disclosure about saying, yes, the mistake has been made and there's been a paradigmatic shift in hospital environments about admitting an error and this needs to be an open conversation with your legal risk team and not just something that's sort of gossiped about or misinformation tossed around at change of shift or when you're out having having coffee together. The thing I want to talk about is trustworthiness. The Gallup poll puts nurses at the top of the list every year. by far were the most trustworthy. So you think about your patient and your bedside maybe with dementia. You know Andrew all the people that you look after as a nurse practitioner in a nursing home and the vulnerability of people and a family and a patient no matter where you're caring for people are trusting you to do the right thing. And if you make an error you didn't mean to make it. They're trusting you to tell the truth. And sometimes that's really hard so people are really limited because they can't speak for themselves. So we need to be advocating for them.
Tess:And in my mind this all comes down to the basic fundamentals of what is the common glue to all of our values and nursing which is relationship, right? And so I mean the times that I remember one...I won't go into the story, but the times that I have sent somebody home and then as a nurse practitioner I can think of two or three over my career that really stick out where you're like quite worried about somebody but you make the decision with the patient that they should go home and they end up then maybe having an event that causes them to go into the hospital or the emergency room because of a big event. And at the time you made the decision based on what you had the, right information at the time, not having a crystal ball, but in collaboration with the patient and then the times that I have called them back and said,"wow, what happened? How are you doing?" You know and it kind of did...that goes miles. I think that has to do with patient relationship based care because it's I don't know we're kind of launching onto a tangent. I don't know if we want to go there. But it's of course nobody is perfect.
Rebecca:I had a mistake made on me as a patient...
Andy:How were you informed of that?
Rebecca:It was really interesting, the staff. It was a medical error, procedural error and it resulted in me having to have more procedures done and the fellow in training didn't want to admit this. So the staff physician came in and said so and so has something to tell you. And he mumbled around and looked at the floor and mumbled an apology about something and said"so a mistake was made and we're going to have to do this other thing." And I was not gracious. I did not trust that person because that person wouldn't look me in the eye. They stood at the foot of the bed in her little white coat and looked at their feet and stumbled around, but what I really wanted him to do was come over to me and establish a relationship with me and sit down pull up a chair and say I have something to tell you. I made an error or this happened and I sure didn't go into this thinking that this was going to happen. But it did and I'm here to apologize to you and it can be corrected but this is what it's going to involve. And so that would have made me feel a lot more comfortable than, so if a nurse had made a medication error, if a nurse came to me and sat down and said instead of a physician a nurse running to a physician. We have to be accountable for what we do. And you go run and tell mummy and daddy you know so-and-so. I did this...
Tess:Or simply write the incident report and not necessarily you know move forward in the best manner that way.
Rebecca:Right. So our challenges are based challenges to reporting or culturally based in your unit in the hospital. We get blamed. Other nurses will blame us for oh well she's really stupid or...no compassion and then that person gets distanced. Everybody will sort of walk away from you because you made a mistake and you must be a crummy person. People gossip. And then what happens is there is a lack of trust. I didn't trust that physician group one iota.
Tess:Well I mean where does this. Also I don't want to interrupt you from your list but where does this take then a really good nurse and not let them thrive in nursing versus saying here's how we rally around and support someone because it could've been me. You know what I'm saying?
Rebecca:It comes in reporting and filling out that incident report or that patient safety report because you did not mean to make that mistake, but they're were contributing factors. You were answering 10 call outs, there were three people needing the bathroom, the room was filled with visitors, the place was chaotic, the technology failed, the pharmacist and a resident made a mistake in calculating a dosage.
Tess:You had a fight with your husband before you came into work today. You know I think that that's one thing and the paper...the human factors. They talk about this in airline pilots and piloting is what did you leave at home. You know and what did you have to assume when you come on. Nobody is super person you know.
Rebecca:When you walk through the doors of your hospital I liken it to putting on your backpack for work and leaving the bags that you carried in from home at the door and yet you really do have to be able to separate and concentrate. But there's so many factors that go into a mistake or a near miss and how important that is
Tess:You guys know that I have to go?
Rebecca:Oh Tessie
Tess:I have to go, but I think this is probably a good time for a break anyway and then you guys can answer direct questions maybe after this is done.
Rebecca:That's a great idea. Were gonna miss you Tessie.
Tess:Well you know I'll be back
Rebecca:I know
Tess:and I'm with you always(laughs)
Rebecca:Andrew and I will be back in just a couple of minutes.
Narrator:Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help. Thank you so much.
Andy:Hey and we're back, Andrew Whitters here, Friends of Flo
Rebecca:and Rebecca Porter. We're talking about medication errors and near misses. Based on a paper that I wrote a few years ago. So we're back to talk about, Andrew you had a question while we were taking a break.
Andy:Well I thought you brought up a really good point about a health care provider a nurse that might make an error. And the difficulty of taking the onus for that error
Tess:The responsibility.
Andy:Right. So you're story of the person that came into your room and stood at the foot of the bed looking at their feet and whatnot. Not that I'm defending those types of behaviors, but I think there is a there is an inherent cultural difficulty admitting that we're wrong. And I think it's rooted in the idea of shame and then the other idea of the sort of legal Sword of Damocles that we...plus as professionals
Rebecca:We take personal responsibility for those near misses or errors that happen, but it's so important to remember that you didn't come to work with the intention of this happening. There are so many factors that go into why a mistake happened and by filling out that that incident report or that patient safety report you are helping the system get corrected.
Andy:It puts the medication error into context...
Rebecca:A broader context and I think that there are some strategies for taking that ethical stance. When I'm looking at this through an ethics lens. And do you think...what I think on the questions that were posted on our media site is that people are struggling with this as an ethical issue. Yes, it is an ethical issue. And research has shown that really for things that affect our willingness to decide to act on whether we would report a near miss or an actual error and that depends on our knowledge of ethics. It depends on how our clinical expertise. If I'm really new I might not want to do it. Maybe I don't care about ethical issues or maybe I'm really passionate about creating an ethical environment and that will influence me and also, what do I think about the kind of influence that I have in my unit where I work? But I think that there are some real strategies and the first one is to be accountable to yourself and your co-workers and that's by how we create a healthy working environment. And what is the communication like on your unit. Is it respectful? Is it based on trustworthiness and patient safety? So we have a responsibility, legally and morally, to speak up. When you are outside your scope of practice or where you are outside your limits of knowledge, that you you speak up and say I don't know enough to be doing this. I will need some help with this. I don't know about this medication or I know nothing about this medication before I give it I'm gonna talk to the pharmacist. This isn't being weak. This is actually putting your professional accountability front and center and it's being an advocate for your patients...
Andy:And certainly acknowledging safety first.
Rebecca:Right. So what do you do when a near miss happens or a mistake has happened. So let's say something has happened, I imagine I have, I don't know that I've made a medication error in my practice but I would imagine it would be a sucker punch to the gut.
Andy:Yeah right, right. Absolutely.
Rebecca:I just can't even believe this happened and so the first thing you want to do is either run away, ignore and pretend it didn't happen. But there's also you have to admit it. Because what if something untoward happens to the patient. And so you can immediately see that having a safe work environment where people aren't being blamed that you can go to your nurse manager or your charge nurse...
Andy:and have a dialogue at the very least...
Rebecca:and have a very good conversation behind closed doors and talk about how this should be disclosed to the family, to the physician who should disclose it and being mindful that making, admitting an error respectfully actually strengthens that relationship.
Andy:Sure it does.
Rebecca:With your co-workers, with the person who ordered the medication that you can say I made a mistake.
Andy:I would say that what I've seen in practice when it's communicated to the patient and family members it's done so as a team. So you have maybe a nurse manager and a couple of shift nurses present that are presenting the error the situation that happened. The majority of the time that I've seen it in practice, family members and patients are forgivingaaa
Rebecca:If it's a heartfelt apology
Andy:And of course when there no harm done and there's...it's understand the context of how it happened
Rebecca:and not as an excuse for why it happened, but these were the mitigating factors.
Andy:Again in my practice I've observed that coming at it in a teen fashion helps to mitigate those angry feelings the feelings of sorrow that I think occur on the nursing side
Rebecca:Stops the gossip
:Yeah, stops the gossip it builds people up it encourages this idea to move on.
Rebecca:And it's an opportunity when you know one of your co-workers has made an error that you could walk over to him and say,"gosh, how are you doing?" That must have been awful for you do you want to have a coffee. How can I help you get through this. And not an opportunity to just start gossiping and blaming. If you choose not to disclose an error what are the consequences.
Andy:Well I would imagine the feeling of guilt. I can't imagine not disclosing an error especially in this day and age.
Rebecca:You know when we talk about patient autonomy and we want people to have information about their care, about their treatments, about how things are going and we respect autonomy. One of our first priorities ethically in our code of ethics is to advocate for the patient. And if we withhold information from a patient we are not advocating for them and we are not respecting their autonomy. Those are two huge violations and what we were talking before in the break is, man, it just erodes trust.
Andy:Oh, absolutely.
Rebecca:You know trust in one another, trust for the patient, for you. And it's so important to talk about near misses or an error at change of shift report. And just to say I missed that antibiotic I filled out a report. Things got really busy, the drug didn't get here from the pharmacy, so you didn't get that drug. I'm really sorry, I filled out an incident report. I said why it happened but you need to know that this happened or I gave an extra dose. I forgot to check the electronic medical record. I went ahead and gave it and realized that the patient had a double dose you know and half the time and this is what I've done to monitor the patient and I've told the patient and I've talked to the pharmacist and I've talked to the physician and we're just going to stay for the next few doses and we all know that. So it's a safety issue. What do you do when people get into the name blame shame. How did you handle that Andrew?
Andy:Well, I consider myself a leader and a team member when taking care of a patient and when I communicate with a patient and their family I I will always tell the patient you are my focus I'm your advocate. You are my leader. Your body your clinical symptoms will tell me what I think you need. I'll give you the recommendations you can accept that or not accept it.
Rebecca:But if a mistake is made...
Andy:So when a mistake is made I I tend to gather all the evidence again, but then I will present it or try my best to be present to present it as a team. And this is what happened. And this is where the failure points. I talk in general terms of something in the system. It wasn't a choice that a nurse or a care provider made, but this is what happened and this is what we've identified to make it better to mitigate that future error again.
Rebecca:Right. It also creates that culture of safety and respect and relationships.
Andy:Without naming names is the important aspect. And you know a patient who might be argumentative might say"well I wanna know why nurse x here didn't recognize that in the first place" and I just go back to the facts. This is what happened, Tt wasn't intentional. I've never seen an intentional egregious error. I think intentionally harming people in this profession and this line of work, it's exceedingly rare ff it all in my experience. I've never seen that.
Rebecca:So you're talking about your role as a nurse practitioner and a leader, but what advice do you have about naming and blaming shaming that goes on among staff nurses. You know in a backroom in the staffroom that change your shift and there's this gossiping stuff going on, oh you know she may she can't believe she did that, I'd never let her near me.
Andy:Simply put if you choose to gossip you're poison. Like you're just poison.
Rebecca:You're part of the problem
Andy:You're a huge part of the problem and it might, even if it feels good to to get some gossip off your chest and to put someone down and build yourself up, I mean that's what gossip is.
Rebecca:So when people start gossiping in the back room and the staff room and start whispering about what happened and you're there right there. It's really hard to speak forward, but it's just to say you know any one of us could've made that error.
Andy:That's what I have typically said. I'm established enough in my practice where people just don't gossip around me. But when I have heard it in the past I say, hey, we're all human. I paint in the context of people make mistakes. No one is perfect.
Rebecca:Any one of us could've done this. And I think for brand new nurses out there and people who are looking for their first job. I remember being terrified about giving medications to patients.
Andy:Well fear is natural and all this knowledge that you're carrying all this training that you've carried. It's it can be hard to trust all of your training it's easy for me to sit here into a microphone and speak to trust your training and trust yourself. But when it's in practice I mean you have a life in front of you and you're in an emergency situation. You let those fears come out and it is difficult. And so what I would recommend is recognize those fears and talk to your colleagues or even your mentors about these experiences that you might have and work through them.
Rebecca:Right. And in a staffroom to have the moral courage to speak up and stop the gossip it's really hard when you're a new person and even as a senior staff person. You have a moral obligation and a great opportunity to work on changing the culture of your unit. But how about some things that we can do to prevent those near misses and to prevent those medications and I think from my research it's really avoiding work arounds. You know those are one of the great sources of medication errors...
Andy:Avoiding shortcuts.
Rebecca:Yeah, so that means making sure that you actually look at the original order before giving a medication that a lot of things get passed along in a medical record get added. I think it happens less with the electronic medical record. But if you haven't seen that original order and the date that it was originally ordered and does this patient really still need this medication...take that few minutes and double check and during rounds or when rounds are being made on your patient, talk, open up, talk about treatment plants and other medication options and make sure you really understand why each and every medication...I think sometimes medications get carried along in hospitals particularly on older patients without really clarifying what it's for, how long it is to be given, and what's the stop date on this medication.
Andy:Or even the need as well. I will interject though with with the advent of how much technology is involved with providing medications. The thing that I see a lot of in practice is when a medication is stopped it is put into the computer format for communication. Oftentimes it is not verbally passed on to nursing report. So I would advise especially new nurses out there who are used to all of our handheld technologies that we carry around with us and use facilities and clinics, to verbally share what's going on with your patient from one shift to the next...
Rebecca:And to other providers.
Andy:Sure, exactly, and don't just depend on the electronic resource or electronic medical record because it can be missed.
Rebecca:So when you see that nurse practitioner coming around or a physician team coming on rounds have your list of medications in hand, have them ready and stop that team and say I would like to review this patients medications to be sure that you agree with everything that's on here.
Andy:Sure. I would also recommend that nursing leaders as well establish a time for appropriate communication in between staff shifts. So 2:00 might be the time to give a report or even a recorder, I've seen that in practice that that is useful I think to some degree, but I still believe that nothing is better than person to person communication.
Rebecca:One of the things that's happening at our hospital is they have bedside rounds. The nurses do bedside rounds on every patient in front of the patient and they go through all the diagnoses and all the medications and the basic activities of daily living so that the patient understands all the medications that they're getting or the family member and understands what to expect and what exactly is going on.
Andy:The patient is actively involved in the patient in my purview should be your focus and should be your leader for your health care plan.
Rebecca:So it's really important for us as nurses to, were at what I call the sharp end of medication administration, pardon the pun. And we are obligated to safeguard our patients. So it's really important to be involved in policy development in your institution to be sure that the entire process of medication ordering and how it's going to be giving, where it comes from, who is giving it is clearly understood by everybody.
Andy:Absolutely
Rebecca:So I think in wrapping up here one of the things that I think I would like to talk on about medication errors as we wrap up is if you've made a mistake or somebody on your unit has made a mistake, is to think about being a second victim because we really need to work hard to help people understand that it really is uncomfortable and we feel fallible, we feel hurt, we feel guilty, we feel panicked. You begin to doubt yourself and not trust yourself and blame yourself when something bad happens. But just the simple act of acknowledging that an error has occurred and that you...and you have created and work in a morally safe environment. They have policies in place that look for the root cause analysis of what happened and why it happened. Helps to understand and just stop and think about how vulnerable all of our patients are and that simply acknowledging it's not simple, but acknowledging that an error has occurred, that taking responsibility for it doesn't really decrease the distress that we feel it, but it leads to really important practice change both in ourselves and at the unit level. And sometimes at the institutional level. And I'll close by saying that our code of ethics is very clear about the care that we take for ourselves and the care that we take of one another. So when an error has occurred is to really look after yourself and forgive yourself and also to be of that kind and compassionate person in your unit for the person that it may have happened to.
Andy:Amen, amen to that.
Rebecca:So I think that's all we got. Have you got anything more, Andrew?
Andy:I don't think I have anything more to add other than to innovate, agitate, and educate.
Rebecca:Be kind to one another
Andy:All right. This is Friends of Flo saying, until next time.
Narrator:Here at NCLEX Mastery we love nurses and especially nursing students, but we need your feedback about this podcast. If you have ideas on topics or questions you want us to answer, shoot us a message, leave a comment, go to our Facebook page and just tell us what you think because we want to help you in the most specific way that you need that help.