Stop Pointing Fingers – Medical Errors
The usual response to an error made in health care is defensiveness, which includes finger pointing, guilt and sometimes cover-up.
No one wants to think they could have made a mistake that could harm a patient. Recently, I experienced that feeling.
A 43-year-old female patient with a history of insulin-dependent diabetes, coronary artery disease and congestive heart failure underwent an outpatient angiographic procedure to correct a blockage in a lower extremity. During the procedure she received medication for sedation over a 3-hour period and vital signs were being monitored. Post-procedure she was transferred to a stretcher and wheeled to the hall for transport to a nursing unit.
At this time, she was awake and oriented and complaining of nausea. I administered the 25 mg of Phenergan�® (promethazine HCl, Wyeth-Ayerst) IV ordered by the physician. The patient was not being monitored, nor was she on oxygen therapy. She was then transported to the nursing unit, where I gave report and then returned to my department.
A short time later, my director asked me to explain what happened to the patient. When I gave him a questioning look, I was told the patient became unresponsive, with an O2 saturation of 68 percent, and narcotic and sedative antagonists needed to be administered.
An event report was written and submitted to our risk manager. When questioned, my first reaction was to become defensive, and then I felt guilty. What did I do? Or not do? There were several factors involved. How much sedative was given? The 25 mg of Phenergan was a normal dose, but did it potentiate the drugs already administered? I was asked why the patient’s pulse oximetry wasn’t being monitored during transport. It was also questioned whether or not I had instituted an unsafe medication order given by the physician.
Denise Barnett, RN, CLHRM, CPHQ, the risk manager at Charlotte Regional Medical Center, Punta Gorda, FL, stresses a team approach to the improvement process. She counseled me to view the event as an educational opportunity. What could we have done differently or better?
THE OUTCOME
Our department instituted the use of a transport monitor and oxygen therapy for all post-angiographic patients who receive narcotics and/or sedatives, and pharmacy is looking into the use of the narcotics and sedatives given during the procedure. Fortunately, the patient recovered and was subsequently discharged.
The incident review process in this case took many days, during which I questioned my own actions and the way I viewed the reporting process itself. Barnett set the tone of the process with her interpersonal skills, integrity, values and knowledge, and she was very helpful with getting me through it.
Traditionally, approaches to health care error have focused on individual responsibility and faultfinding. It is important to move away from an atmosphere of blame to one of identifying and correcting the problems in the system that lead to error. Many health care facilities are moving toward systems-based approaches that stress system errors and improvements through shared accountability.
ERROR PREVENTION
Health care workers do their utmost to give the best care to patients. Though we are conscientious professionals, mistakes do happen because we are human. Many of us have known colleagues who have been involved with health care errors and witnessed counterproductive attempts to “punish” those involved. These attempts include professional discipline and sometimes legal liability, not to mention the embarrassment to the employee involved in the error.
Sanctions imposed after mistakes are made rarely, if ever, address the underlying causes of the error. Error prevention in the past was largely ignored.
All health care professionals involved in patient safety issues should have an interest in reducing error. Identifying and correcting systems errors decreases personal and facility risk of liability, regulatory sanctions, negative publicity and, most importantly, harm to patients.
INCIDENT REPORTS
The process for incident review usually involves event reporting. Ultimately, a constructive incident reporting system will achieve a better understanding of a facility’s problems related to the health and safety of patients. Reporting an error ensures quality performance in the facility, which is an ongoing process. Incident reports should be filed in a timely manner, so that investigation of the incident may begin promptly. Because of possible reprisals, staff understandably may be reluctant to report incidents involving patient care.
To achieve the best results for all concerned, a collaborative approach should be used. When the error is identified and the correction process begins, it promotes important opportunities to prevent duplication of the error. An interdisciplinary, no-blame approach fosters process thinking and problem solving to correct systems errors.
Incident reporting also should not be looked on as an exercise in futility. Staff sometimes believes that it is only extra paperwork, and managers do not act on the reports. It is im.portant for the risk manager to educate the staff and it is to be expected that all incident reports are followed up. Josh Putter, CEO, and Peggy Greene, RN, associate executive director of nursing, both of Charlotte Regional Medical Center, are forward-thinking administrators who use a nonpunitive approach to occurrence reporting, and foster a positive environment for improving patient safety, from management to employees of the facility.
Documenting is an integral part of the reporting process. Only facts should be written and the report should be clear, concise and comprehensive to facilitate appropriate follow-up interventions. It is the task of the administrative staff to set a fair tone toward direct-care workers. It is important to assure individuals that they are not unfairly targeted because they self-report errors more consistently and accurately.1 The policies and procedures of the facility must ensure the safety and well-being of its clients.2
AN ONGOING PROCESS
The event report process may be assumed to be successful because the investigation has been completed and interventions were initiated. Yet the completion of an investigation does not necessarily ensure that the quality of care has been improved. Ongoing observations of clinical and administrative interventions must be conducted through routine safety and clinical inspections, walkthroughs, informal discussions with staff and attendance at clinical-care meetings.2
The Institute of Medicine’s (IOM) Novem.ber 1999 report, To Err Is Human, highlighted a critical aspect of health care quality – the ability of the system to render care to the patient without causing injury in the pro.cess. The report called for “rapid and sustained action to reduce the incidence of pa.tient injury and death due to mistakes in the care that was given.” The IOM recommended that actions to improve safety be based on information about the underlying causes of the errors. The report concluded that “errors are the result of problems in the system of health care delivery, not the fault of incompetent or malicious individuals.” The IOM also outlined four critical steps in reducing the risk to patients from errors in health care delivery:
create a national focus on medical error and institute leadership for improving care;
develop systems to collect information on errors that are occurring and learn from those mistakes to reduce errors for other patients; raise expectations about the performance of the health care systems; and institute safer practices in the delivery of health care;
The National Institute of Health’s guide, Improving Patient Safety: Health Systems Re.porting, states that “information can be used to change current practices to foster safer health care no reporting system is useful unless that information emerging from the system is actually used to reduce the risk to patients.”
The American Nurses Association (ANA) has been active in its efforts to encourage pa.tient safety and reduce risks due to systems errors. ANA also advocates moving away from a “blame” atmosphere in health care.
Nursing plays a key role in reducing health care errors by sharing perspectives. Their clinical and organizational expertise allows nurses to identify systems-related errors and help correct those failures.
