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 patient-safety-10-638are 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 nursecakeconnected, 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.




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. 




8 thoughts on “Patient Safety and the Blame Game

  1. Interesting article and thanks for sharing. To create a culture of safety you need to have a system where there is no blame. We (nurses) are human and mistakes will be made. Owning up to a mistake takes courage but we do it for the good of the patient. As a nurse I also made mistakes, but thank God no one was hurt. Very sad that a nurse or doctor would kill them selves for making a mistake. We as an industry can do better.

    Liked by 1 person

  2. Good luck with all that. I totally agree with all you said but you will never get the corporate people to care. I was lucky enough to have experienced the day when hospitals were run by nuns for little or no pay. They cared about patients and staff. Corporates are business people and that is all. They care about their bonuses and that is all. There are probably 3 hospitals in this country that are truly about the patient.(St. Jude’s comes to mind) I just get sick of the advertising and buzz words like core values and quality care. They are just bs that some of the public fall for. I uses I’m Debbie Downer. So glad to be retired and away from all that. Those are all the reasons why I would never encourage someone to go into nursing these days.


  3. Janie, this is so on target. They get us because we are inherently caretakers. We go ahead and accept unsafe assignments because we don’t want no care provided.
    I believe that we can create change. I don’t think most non medical people understand the conditions at hospitals and nursing homes. Most people evaluate their care on the rapport they have with the people caring for them so as long as they are treated with kindness they feel they had an excellent at hospitals and nursing homes. Most people evaluate their care on the rapport they have with the people caring for them, so as long as they are treated with kindness they feel they had an excellent stay.
    We need to educate the public.
    I am reminded of the movie Network. “We’re mad as hell and we’re not going to take it anymore”
    I think this is what needs to happen.
    Too many nurses are pushed out of the field through punitive measures that far exceed the incident.
    This needs to change.


  4. I feel so despondent as a nurse. I am a returning adukt learner – I yr post graduate. I went into nursing because it was what I wanted all my life. I’m intelligent, but take a little (not a lot) of extra processing time. This results in catching errors others have left and exceptional documentation. I’ve received kudos from supervidors, coworkers, and pts alike, but none of this matters in the long run. What matters is…getting out on time. So I leave orders in that should be dc’ed. I leave pts needs, and with many, minimal wants, unattended to. I address only the bare minimum. And this breaks my heart. I’ve already gotten into an accident r/t fatigue. I am finishing out my “year of med-surg ” which I actually love and hoping to find a job with somewhat similar pay, but a little less stress. I am a good nurse, but being attentive and thorough is no longer the priority. Getting finished by a certain time is. I’d go off the clock to finish documentation in order to be thorough, but that isn’t an optiom either. I just find it so sad that this is what pt care has come to.

    Liked by 1 person

  5. This is so very true, even though at the end of the day this is a business there is no need for these corporations to be greedy. Run a business and no they shouldn’t starve either but there is PLENTY of cushion to staff properly. Thank you for leading us.

    Liked by 1 person

  6. Yes it is about time that we started speaking out for ourselves as nurses! I have always worked in the ED and love emergency nursing. I quit my job last year mostly so that I could finish school (Family Practice Nurse Practitioner) but really the plan was to work part time until I finished. But I was charge nurse in a 20 bed (plus hall beds) ED and I had up to 12 patients of my own, and there were many days when we had no secretary, so I had to do that job too. I just got too stressed with taking on way too much. It became so dangerous and most of our good nurses left due to the daily understaffing. I left too. I just dont understand how these hospitals get away with running a hospital so understaffed.

    Liked by 1 person

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