To Err is human but do No Harm… | Episode 019


Episode summary introduction: As Nurses we are taught about medication administration, and the 5 rights. We are also taught to hold our nursing license in high regard. We as nurses should always strive to help and never harm our patients. Unfortunately, there are factors that can hinder proper medication administration and nursing judgement. Not all medical errors originate from nurses but come from doctors as well.

Topic 1: Why do medical errors occur? There are several reasons, beginning with transcription difficulties to administration errors.

Topic 2: Kim Hiatt’s story is discussed in this topic.

Topic 3: Nurses are expected to use their “nursing judgement” for many situations that arise on the floor. Nurses must ask questions. Medications are used “off- label” for a variety of situations, however, it can still be evidence based data that has been proven to be safe and effective. If you don’t know, you need to ask.

Outro: It is estimated that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. If more healthcare workers actually reported errors and near misses, then data would be more reliable. With reliable data, systems could be put into place to help prevent errors in the future.

References:

Stories of errors

https://www.athenahealth.com/knowledge-hub/practice-management/first-blame-nurses

http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.XuV5x0VKjXM

https://abcnews.go.com/Health/nurse-patient-paralytic-antacid/story?id=14997244

https://www.thenewsherald.com/news/doctor-says-nurse-gave-wrong-medication-to-patient-henry-ford-wyandotte-hospital-now-refutes-that/article_a5dedb1a-9dcf-11e9-a784-531e897c9164.html

https://www.rd.com/health/healthcare/doctors-medical-mistakes/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118964/

https://apnews.com/37e3f64408b04099b65657d0a7b4b44d

https://slate.com/technology/2015/04/doctors-bully-nurses-hospital-mistreatment-is-a-danger-to-patient-health.html

https://slate.com/technology/2015/04/doctors-bully-nurses-hospital-mistreatment-is-a-danger-to-patient-health.html

https://www.nursingcenter.com/journalarticle?Article_ID=423284&Journal_ID=54030&Issue_ID=423107

https://www.middleeastmedicalportal.com/the-domino-effect-of-medical-errors/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016741/#:~:text=It%20is%20believed%20that%20preventable,discrepancy%20on%20discharge%20medication%20reconciliation.

Prevention

https://pubmed.ncbi.nlm.nih.gov/25077248/ - To err is human

https://minoritynurse.com/10-strategies-for-preventing-medication-errors/

https://nurseslabs.com/6-things-nurses-know-commit-serious-medication-error/

https://www.beaconjournal.com/article/20151026/NEWS/310269156

https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/

5 rights

http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx#:~:text=One%20of%20the%20recommendations%20to,route%2C%20and%20the%20right%20time.

https://injury.research.chop.edu/blog/posts/follow-5-%E2%80%9Crs%E2%80%9D-medication-safety#.XuWHJkVKjXM

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/

https://www.rn.com/nursing-news/safe-medication-administration/

https://www.hcpro.com/NRS-201830-4931/Practice-the-six-rights-of-medication-administration.html

Why errors happen

https://www.washingtonpost.com/health/2019/10/23/broken-health-care-system-is-causing-rampant-burnout-among-doctors-nurses/

https://www.ncbi.nlm.nih.gov/books/NBK519065/

Reporting errors

https://rn-journal.com/journal-of-nursing/right-thing-wrong-results

https://www.thehealthy.com/healthcare/doctors/doctors-confess-their-fatal-mistakes/

https://amednews.com/article/20110815/profession/308159942/4/

https://www.courthousenews.com/nurse-says-clinic-fired-her-forreporting-surgeons-repeated-errors/

Call to action:

Local Resources:

http://www.nln.org/docs/default-source/default-document-library/nursing-judgment-final.pdf?sfvrsn=0#:~:text=Practical%2FVocational%20Nursing%20Program%20Outcome%3A%20Nursing%20Judgment,ways%20(Benner%2C%202010).

Nursing judgement

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