Patient Safety and the Blame Game

Have you ever made a medication error?

I have.  I flushed a ‘heplock’ (we used to flush IV’s with heparin for the young kids) with 3 mL of 1000 unit/mL heparin. Instead of 100 unit/mL heparin.  Of course, this was in 1990 when I was pushing a med cart up and down the open bay ward on the 7th floor of Portsmouth Naval Hospital.  One multi-dose vial had a green label, the other a blue label. Nothing had a red stop sign on it.  It didn’t have a warning. We were supposed to read the vial.  I didn’t. I was busy and still had 22 patients to go.

I had to pass meds for 30 patients, on an open bay ward.  Yes, beds lined up next to each other.  I was constantly interrupted.  There were drawers in the cart stocked by pharmacy labeled by bed number.  No kidding.  I had a book on the top of the med cart so I could look up the drugs I had never heard of.  I was a Navy Hospital Corpsman and went to school for several months to do what it took you years to learn how to do.

Also, I think I gave the first TPA-like treatment to an ischemic stroke patient.  BONUS! 

When I told my charge nurse, he said that I should read the vials more carefully, and he told the patient’s nurse to watch for signs of bleeding.  He explained that it was better to check the vial against the MAR 3 times.

That was it.  No write up.  No Blame.  No Shame.  I have never given a medication without checking it 3 times again.

And then there was Kim Hiatt, who committed suicide when she was fired and blackballed for making a medication error.  Five years ago.  Have we gotten better?

I think we talk the talk, and do not walk the walk.  I think we may have gotten worse.  

We have taken away multi-dose vials, we have barcode scanning for med passes. Nurses are actually disciplined for not barcode scanning, but hospitals are not disciplined for low staffing levels.  Nurses are the very final line of defense in patient safety. Not just any yahoo can pass a nursing college curriculum.  We are taught to analyze, anticipate danger, and critically think. If we have too many patients to care for, medical errors will happen and people will die.  Medical errors are happening and people are dying.  We hear about it on the news, in our professional journals, and from our coworkers.  People die in the hospital.

And we are blaming nurses, instead of the broken process of understaffing the inpatient units to save money.  We offer the nurses almost no support staff to take care of jobs that can be delegated.  We give them too many patients.  We add on extra charting, extra assessments, extra forms to sign, hourly rounding for patient satisfaction, and expect miracles.

Sorry, health care organizations.   We are through allowing it.  You don’t get to have ridiculously high bonuses and mandated overtime, while cutting our benefits, and endangering our patients without a reaction from us.  This is a new age. Welcome to social media.  We are connected, we are engaged, and we are ready to advocate for ourselves.  You don’t get to eat your cake and have it too.  Even this yummy cake.

As I said before…

 

We are coming for you.

Love,

Janie

 

SMYS For Change is the place you want to be if you are sick and tired of being considered an expense and a liability instead of the completely indispensible and largest segment of healthcare providers.