Imagine this hypothetical but possible scenario: an elderly patient had died from multi-organ failure and blood poisoning. She was accidentally given 10 times her prescribed dose of anaesthetic by a nurse. While the overdose was not the cause of death, the blame fell squarely on the nurse.
When it comes to medication error incidents, nurses often can become convenient scapegoats or fall-guys. Shirley Heng, Chief Nurse at Khoo Teck Puat Hospital, talks to Hospital Insights Asia on how hospitals can put in place processes and adopt technology to minimise human errors, and foster a “no-blame” culture with a communicative team-based approach.
Finger-pointing doesn’t help
Human errors can happen at any step of the treatment process. Administering medication to patients is often the last mile. Prior to it are other steps such as packing, prescribing, and verifying. Nurses are often blamed because they are the ones tasked to administer drugs to patients and therefore are expected to have ensured the final check.
Yet, penalising human errors, when they accidentally happen, will not prevent future errors from happening. More than helping, the threat of punishment makes nurses more fearful of reporting errors. It does nothing to prevent these mistakes from happening again.
While it’s true that nurses need to understand their responsibility to provide accurate and appropriate care for patients, trusting in their abilities and letting them know they have support from the management are better than blaming them when errors happen.
Errors may be prevented
“To err is human,” as they say. Mistakes happen due to several reasons that sometimes are out of our control. Often, factors related to workload and prescriptions cause medication errors.
Staff shortage leads to a whole bunch of problems. Distractions occur especially when doctors and nurses take on a heavy workload or have many concurrent activities or tasks. But this can be mitigated. For Heng, a dedicated time for medication administration rounds, staff support (for example, responding for each other when patients or another personnel call), and reviewing traditional ward activities may be done to minimise clashing of other activities with medication administration, like ward rounds and scheduling of procedures for patients.
On another note, technological support can address misinterpretations in prescription and medication charts. “We have already shifted to electronic medication order and administration so errors from misinterpretation are minimised, if not removed,” Heng shares.
While no technology can lighten nurses’ emotion or perception of being blamed, Heng believes that technology must be used to “support the care providers involved in every step of medication management, starting from ordering to administration.”
A no-blame culture is key
In case medication errors occur in a hospital, a non-punitive approach must be used. Eliminating a culture of blame makes nurses more open and communicative, which are highly important in mitigating errors early on.
Creating a no-blame culture involves encouraging a root-cause analysis in looking at reported incidents. Reviewing every segment of the process in which errors can happen lets the staff know they are supported. “It is an ongoing battle to investigate error sensitively and ensure our staff, especially our nurses, feel supported as second victims,” says Heng.
An ideal scenario to address incidents should be transparent. The nurse manager receives the first report of the incident, interviews the staff involved, creates an incident report which includes a root cause analysis, and shares findings to various teams for learning and quality improvement.
Equally crucial is using a multi-disciplinary approach. Insights from doctors, nurses, and pharmacists help move the investigation forward. Regular communication, likewise, has to be encouraged for different staff levels.
Blaming will get us nowhere. Besides preventing medication errors, hospital leaders have the responsibility to let their staff know that finger-pointing is the last thing they’ll ever have to worry about as they care for patients.
Catch Shirley Heng on 8 December 2020 for a panel discussion on “Stretching an already stretched workforce: Managing nurses”. Register for HMA Virtual today!
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