Errors as Opportunities

I really like the quote that our instructor shared with us this week: "Your best teacher is your last mistake." It is really so true, especially in the medical field. I'm sure that all of us have made mistakes that we don't want to repeat ever again, so they are ingrained in our brain as a teaching moment. One thing that I have allowed mistakes to teach me is a very simple lesson-- that is, everyone makes mistakes as a nurse at some point and if you are lucky enough to work with supportive coworkers, then you should not feel like anyone is looking down on you for an error. I have a great example from my unit. It did not happen to me, but with a few of my coworkers/friends. The majority of our postoperative patients are prescribed IV Toradol after surgery to aid with inflammation and pain. There was a patient who was over the age of 65 that had received three doses of 30mg of Toradol after surgery. Anyone over the age of 65 should receive only 15mg of Toradol at a time per dosing recommendations. The medication was ordered by the doctor, verified by pharmacy, and then given by the day shift nurse, and the following night shift nurse. The error was finally caught by the next day shift nurse and was corrected at that time. The nurse who caught it immediately stepped up and identified the problem and did not try to hide it or act ashamed because of the error. Instead, the problem was dealt with and the patient was thankfully not harmed because of it. The nurse could have easily tried to hide the mistake, but instead we all were aware of it and it offered us a great teaching moment. We are now all very diligent about checking the patient's age and the dose ordered.
I would say this was a "sloppy mistake" (Briceno, 2015). All of the nurses knew the dosage recommendations, but lost concentration and made the mistake due to not paying enough attention.
It made an impact on all of us to be more aware of medications being given. Thankfully our charge nurse is very easy to talk to and she did not belittle anyone or make anyone feel stupid for the error. Instead, she used it as an opportunity to talk to her staff and also to the pharmacy. The doctor's nurse associate was also notified and a change was made to the standard post op order sets. I would say that my charge nurse handles errors with a positive approach and is also never ashamed to let her staff know when she has made an error herself. Knowing that our leader isn't perfect helps me to feel more comfortable speaking with her when I have concerns or have made a mistake.

However, I also have worked with a leader who handled conflict very poorly and I lost a lot of respect for her. On a unit that I worked on prior to the one I'm on now, one of the charge nurses pulled me aside and asked how I liked working with a specific patient care technician. She did not give me a chance to answer before she jumped in and told me how she felt about him. She let me know how little she thought of him and made some very rude comments. I really enjoyed working with this PCT and thought he did a great job and I told her that. The whole situation left a bad taste in my mouth. I found it to be very unprofessional for my charge nurse to ask me about a coworker and then egg me on to hopefully say something negative about him. This situation has helped me to decrease my gossiping and keep mean comments to myself. Let's be honest, the hospital is full of gossip and rumors spread like wild fire there. I have been actively trying to distance myself from the gossip and act more like a leader by making positive comments and offering constructive criticism in hopes of building up our team, not breaking it down.

The video "Interruption Awareness" was very eye opening in my opinion.

 I know that nurses deal with a lot of interruptions from patients, family members, doctors, other nurses, alarms, etc, but the exercise of counting by 4's showed just how those interruptions can disrupt our thoughts from an easy task. Just this week I was speaking with a patient about discharging home later that day and she asked me about insulin and if diabetes management would come talk to her again before she went home. I told her that if they didn't come by a certain time that I would call them and make sure they talked to her before she discharged. She asked me "How do you keep track of all of this? How do you remember everything?" I remember smiling and thinking "Because I'm awesome." I didn't say that of course, but it did get me to thinking about how many requests from patients nurses get in between the every day tasks that need to be completed.
I think that a good leader will recognize when a nurse is struggling with keeping up with all the interruptions and will step in and take charge. Even just answering a few call lights while that nurse takes the time to catch up with charting or making phone calls is so helpful. I work with a very dear friend who is always saying she is fine and doesn't need help with anything when she is asked, even when the rest of us know that she could use the help. Instead of shrugging my shoulders and saying "okay", I have learned to just jump in and take some of her responsibilities off of her plate when she has a lot going on and I don't. Something so simple as just starting IV fluids on a new post op patient can help tremendously when there are a lot of other things going on.

I do believe it is true that errors are sometimes made when staffing levels are not adequate. The unit I work on has increased the number of surgeries each week by discharging some of the patients a day sooner than they would have a year ago. Because of this, the staff has felt quite overwhelmed with the increase in patients and we have asked if there will be another nurse or PCT hired to help with the increase. I'm not sure if that will happen or not, but in the mean time my charge nurse has made some changes to help us out throughout the day. The main way is by assigning the surgeries to the staff in a staggered fashion. Meaning that hopefully the same nurse will not get 2 patients back from surgery at the same time.
On other units the staffing is never adequate, which leads to a lot of float staff being used. I think that it is an endless circle when a particular unit is known for giving one nurse 6 patients, and they are not able to retain their staff because of it. I do feel pity for the leaders in charge of those units who have not been approved to hire more staff as I think that sometimes that is the only way to stop the revolving door of nurses in and out.

References:

Boynton, B. (2012, January 3). Interruption awareness: A nursing minute for patient safety. [Video file]. Retrieved from https://www.youtube.com/watch?v=PGK9_CkhRNw

Briceno, Eduardo. (2015). Mistakes are not all created equal. Retrieved from http://blog.mindsetworks.com/blog-page/home-blogs/entry/mistakes-are-not-all-created-equal