Thursday, April 11, 2013

A Culture of Safety

I was standing at the counter when it hit me.
I became nauseous, my knees buckled, and I almost fell to the floor.
I had been uncomfortable mixing the IV magnesium.  It just seemed like too many vials.  Then there was the conversion from milliequivalents to milliliters and all.  I checked with another nurse, but like me, she was inexperienced.
It was a busy second shift in the ED.  The more experienced nurses were involved in a bad trauma.
My patient was breathing poorly, the result of years of smoking.  The magnesium was designed to improve his breathing, but instead he got worse.  We had stopped the IV and intubated him and he was now "stable".

Then, out of the blue, it hit me.
I had mixed the IV at 10 times the concentration!
My preceptor was out of the trauma by now.  I told her and then the admitting doctor, who set her pen on the counter, turned to me, and said, "it will be alright".

I have told this story to many a new nurse.  This week I told it to the Quality of Care Advisory Committee at the Connecticut Department of Public Health.  It was my first meeting on that committee as a representative of the AFL-CIO.

My point was this.
If we want to establish a Culture of Safety in health care, and I believe we should, then we need to have non punitive reporting.
The airline industry has adopted this philosophy and as a result "near misses" have decreased because systems have improved.

A few weeks after my med error, my boss, Sue Davis, called me to the office.  We talked about the error and she said,   " I know this will never happen again".  It never has.  But more important, system changes were put into place to decrease the chance that this or other errors would happen in the future.

No health care provider intends for an error to happen.
The incidences of suicide increase after a nurse makes an error.
Increased reporting of errors or near errors will improve the safety of all patients.
That is why, in my opinion, health care workers need to be encouraged to self report and know that it will not be held against them. This is not always the case.

My patient, he survived.
I am sure that many others have been and continue to be safer, because of the many system changes that followed.
This nurse, I survived too.