September 11, 2014 at 3:36 PM #16113
Jason Hautala RNMember
A nurse (not me) made a bad mistake at work. She covered the mistake, and thankfully no harm was done, but the potential was there for a very bad outcome. Once she realized everything was going to be ok, she decided not to report it for fear of losing her job and/or license. My facility states the QMM process is used to improve workflow and patient safety, and it is NOT a punitive process. Regardless of what they say, it is, in fact, a punitive process.
Is there some way we can encourage people to self report when they make a serious error so that others can learn and additional follow up can be performed on the patient as needed? The way things are now, there is incentive not to report your own mistakes (if you didn’t chart it, you didn’t do it.)
I encourage people to take responsibility for their own actions and pay the piper when needed, but I understand why some people do not self report, especially if they feel admin is looking for errors to build a case for termination.September 13, 2014 at 3:09 PM #16135
I am a new grad (graduated in Dec, passed the NCLEX in Feb, had a job less than a week later. Did 12 weeks of orientation on a busy Medical floor (which I absolutely love) since finishing my orientation I have made a few errors, the worst one was a week ago, the catch was I didn’t realize I made the error until 24 hours after it happened. Quick background, pt had an order for Levemir, 5units, we rarely use vials, almost always use pens, I had never worked with an insulin pen and I ended up giving 50u vs 5u. I had the insulin double checked per policy and that RN over looked it. When I realized my error my first thought was “the pt was fine, no one needs to know” I knew in good conscious I couldn’t do that and I fessed up to the error. My reasoning? The person who prevented a second error told me she had almost made the same exact error and I knew there was a training hole that needed to be fixed. I submitted my error, told my unit manager what happened and now we have a new training policy pertaining to Insulin syringes. My point is…. We are humans. Errors happen. Something can be learned from every error and I know that error won’t happen to me again.September 13, 2014 at 3:10 PM #16136
I had only worked with the pens. Not syringes.September 13, 2014 at 3:28 PM #16137
This really sounds like a hopeless case. Sadly. Who would report/confess human error with fear of termination, or the hierarchy building a case on you? I readily admit my error, but I would not do so in that environment. I think that is a big error in the nursing hierarchy to make this sort of environment where people know that admitting error is actually going to be punitive in nature (despite what they say): it’s the failure of those in charge and cannot possibly result in a good learning environment and I’d imagine it would be a horrible place to work.
The only way to encourage self reporting IMO is to actually have a non-punitive environment of reporting, or be allowed to do so completely anonymously and provide bare minimum of details.
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