NUR 630 Topic 2 DQ 2

Sample Answer for NUR 630 Topic 2 DQ 2 Included After Question

Two nurses make a medication error: One causes an adverse event with a patient and the other does not. Should the nurses be disciplined, and, if so, should they be disciplined the same way? Why or why not? How would this be addressed in a just culture?

Knowledge Check

Why is Just Culture an important concept to consider in a health care environment? Is this concept relevant to your organization?

A Sample Answer For the Assignment: NUR 630 Topic 2 DQ 2

Title: NUR 630 Topic 2 DQ 2

In a Just Culture associates know that they can be open and honest about concerns and mistake without the fear of punishment.  A Just culture focuses on open communication, support for uncovering unsafe processes, and a goal of learning from past mistakes.  In an environment where mistakes are immediately punished people are more likely to hide or cover up when they have made an error.  Due to this lack of transparency problems and system failures are not addressed and continue to happen.  There was a time in my organization that we did not have a system-wide process for Just Culture.  But several years ago we started the journey to become a High Reliability Organization and it has truly changed the culture of our hospital.  Every meeting we have starts with a Safety Moment, Near-Miss, or Good Catch.  In our hospital wide safety huddles each day we discuss safety concerns and whenever there are issues we do Root Cause Analysis to dive into how to prevent future issues.  

Murray, J. S., Lee, J., Larson, S., Range, A., Scott, D., & Clifford, J. (2023). Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Quality, 12(2)https://doi.org/10.1136/bmjoq-2022-002237

Pozzobon, L. D., Lam, J., Chimonides, E., Perkins-Meingast, B., & Luk, W.-S. (2023). Adopting high reliability organization principles to lead a large scale clinical transformation. Healthcare Management Forum, 36(4), 241–245. https://doi-org.lopes.idm.oclc.org/10.1177/08404704231162785

A Sample Answer 2 For the Assignment: NUR 630 Topic 2 DQ 2

Title: NUR 630 Topic 2 DQ 2

In the case of this medication error, I’m not sure the word discipline is the correct word to use in this instance.  Most nurses (all who are big enough to admit it) make medication errors at some point in their careers and should be taught to openly admit a mistake.  I tell my co-workers that if they can find a perfect nurse, introduce her to me, so I can see what one looks like!!  When a medication error is found, the error should be brought to the attention of the nurse who made the mistake. 

The nurses should be given the chance to explain what happened as there are a million reasons for a medication error.  One of my biggest medication errors was due to liquid morphine in which the instructions were very confusing.  I even had another nurse check my dosing because it didn’t seem right.  After we both agreed it was the right dose, I gave my patient a HUGE dose of morphine and he ended up in the ICU.  Thank goodness, the patient survived, but I felt SO bad.  The worst part was having to tell the patient’s wife, who turned out to be a retired nurse.  She was so wonderful about the whole thing and stated that her husband just took a long nap.  That incident has always stayed with me and has made me a more conscientious nurse because of it. 

Many mistakes are made when a nurse is rushed, stressed or the instructions aren’t written clearly.   Personally, it would be interesting to study how many nurses make medication mistakes and when there is no adverse reaction, the error goes unmentioned and unnoticed.  Nurses should foster a more forgiving atmosphere, especially for the incoming new nurses.  So, yes, I believe that both nurses should have the “mistake” brought to their attention, but if they are “disciplined” in the same way, it is a guarantee, that neither nurse will come to a manager when another medication mistake is made.  The nurses should be able to trust their managers or co-workers and there should be a level of support by the organization.  

The term ‘just culture’ is commonly used to “describe processes within organizations aiming to achieve a fair conclusion for those involved in an incident or a near miss. Key to a just culture is a focus on openness, repairing harm, and learning rather than blaming” (van Baarle et al., 2022).  In a just culture, when a mistake is made, the mistake is used as a learning opportunity.  What was learned from the mistake is then used to improve processes and procedures so that another mistake in that area is not made again.    

Reference

van Barrle, E., Hartman, L., Roojjakkers, S., Wallenburg, I., Weenink, J. W., Bal, K., Widdershoven, G. (2022).  Fostering a just culture in healthcare organizations: experiences in practice.  BMC Health Services Research.  22, 1035  https://doi.org/10.1186/s12913-022-08418-z.  

A Sample Answer 3 For the Assignment: NUR 630 Topic 2 DQ 2

Title: NUR 630 Topic 2 DQ 2

Deciding whether a nurse should be disciplined for making an error is not an easy or quick decision.  There is much more involved with errors than just the human behavior.  Healthcare workers, especially nurses, work with many predetermined processes and procedures that they may or may not have had involvement in developing or even been educated properly on.  If processes do not work properly and are apt to fail, this can set nurses up for failure, in which case the process is to blame, not the nurse.  Human behaviors can differ as well, ranging from true human errors to reckless willful behavior, and several points in between.  Human error in itself can be individual based or system based, in which processes or systems are set up to fail (Institute for Safe Medication Practices, 2020). 

Nurses can also exhibit at-risk behavior, where nurses may choose to take certain shortcuts thinking no harm will come of it (Institute for Safe Medication Practices, 2020).  They didn’t necessarily choose to make a mistake, maybe they just chose to bypass certain parts of a process that are designed to prevent errors.  Reckless behavior also exists in nursing, where some may choose to knowingly take risks where the consequences are understood to be great, but they make the conscious choice to move forward with the behavior anyway (Institute for Safe Medication Practices, 2020).  Such behaviors may include making the choice to work while impaired by alcohol or controlled substances, or even sharing passwords to avoid having to have an actual witness present while administering high-risk medications such as insulin.

  The key to organizations promoting a just culture is to first determine which of these behaviors each nurse exhibited, and deciding how to handle the situation individually from there (Institute for Safe Medication Practices, 2020).  No two situations can be handled the same because no two individuals behave the same way in certain situations.  And even though one error resulted in significant patient harm and the other did not, this does not tell us much about the choices each nurse made or whether the system itself failed, setting them up for errors as well. 

Before determining consequences for any event, I first conduct a thorough investigation to find out why the event occurred and any ways that it could have been prevented, either through personal behavior modification, or through system or process modification.  Even if it is determined that the nurse acted with reckless behavior, I still turn the event into a learning opportunity for all, highlighting what errors occurred, and what we can all learn from the situation.  I feel this is one of the best ways to turn thoughts about event reporting away from them being viewed as punitive to being viewed as opportunities to lean and grow as professionals all while preventing harm from coming to our patients. 

So when situations arise such as medications errors, especially if more than one occurs within a short time-frame, I try to look at what processes might have failed to allow these events to happen.  I also look at other factors like whether this is the first or fifth medication event for a nurse, and whether this behavior is becoming a pattern.  Only after all of these factors are considered can you really decide whether any consequences should come of the event, and it may be possible that events where the patient did not experience adverse effects may even carry a greater consequence than events where the patient did suffer adverse effects. 

References:

Institute for Safe Medication Practices. (2020, June). The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. Institute for Safe Medication Practices. https://www.ismp.org/resources/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture