The video “Chasing Zero: Winning the War on Healthcare Harm, highlighted the fact that as nurses and health care workers we are human and make human errors. (Chasing Zero, Because of our line of work, these errors if serious, may be fatal. As recently as a few years ago, nurses and health care workers may have been afraid to report errors due to the fear of being fired or disciplined harshly. Healthcare supported this punitive system. Then the viewpoint changed to a non – punitive system where reporting errors were encouraged and supported and opportunities to learn were given. The healthcare community started to see that there were many things contributing to errors, not just the person committing the error. It is important to continually bring near misses and errors to light in order to analyze how we can develop systems to prevent these errors. Recently it was brought to light that a nurse from Tennessee who committed a medication error was found guilty of reckless homicide and would possibly serve a prison sentence. Fortunately, the nurse was given three years parole, but lost her nursing license. In this case, the negative thing she did was override a safeguard on a medication cabinet, and ignored four pop ups about the medication she was about to administer (verconium instead of versed). These pop up reminders were in red and said “Warning Paralytic Agent”. (Kelman, 2019). This nurse obviously could not defend these actions. Nursing organizations and nurses across the country are afraid that because of possible convictions of nurses for errors going forward, they will fail to report errors. This would be devastating for patient safety and quality. We positively affect quality and safety in the care of patients by following policies and procedures to the letter. We need to question anything that we sense is wrong. When a patient questions something we need to listen and investigate. Performing nursing research is also positive for patient quality and safety because it gives us evidence based practice which is the best possible care for the patient. Nurses and health care workers negatively affect the quality and safety of patient care by bypassing or overriding systems put into place to prevent errors and by not listening to their patients. Anytime we fail to follow a policy or checklist exactly as written there is a possibility that an error will be committed. Two examples I have seen are a catheter related urinary tract infection which may have occurred due to poor sterile technique on insertion or opening up of the closed system. Another example is a catheter – related blood stream infection possibly caused by poor aseptic technique, not using the appropriate skin prep or failure to do dressing changes as per policy. Again, the actions to take to prevent these infections is to follow the policy and procedure and checklists for insertion and maintenance of the catheters.
Kelman, B. (2019). The RaDonda Vaught case is confusing. This timeline will help. The Tennessean.https://www.tennessean.com/story/news/health/2019/03/27/radonda-vaught-vanderbilt-nurse-homicide-trial-vercuronium-versed/3216250
Mitchell, G. (2022). RaDonda Vaught: Former nurse in court over drug error avoids prison. Nursing Times.https://www.nursingtimes.net/news/hospital/radonda-vaught-former-nurse-in-court-over-drug-eror-avoids-prison-16=05-2-22/
QSEN.Org. (2010). Chasing Zero: Winning the war on healthcare harm. Care Fusion, AORN.TMIT.
qsen.org/publications/videos/chasing-zero-winning-the-war-on-healthcare-harm