Though I am concerned regarding criminal charges, at the same time, the definition of a safety culture acknowledges that when human error occurs, the system should be analyzed to prevent similar actions occurring in the future. However, there is recognition that when there is reckless behavior, some form of disciplinary action should be taken. I have read the actions taken to override (it took quite a few steps to obtain the wrong drug) and in my estimation the behavior was reckless. There was also a system failure in that the medication should not have been available at all. But ultimately, the nurse becomes the final safety net because it is at the point of administration. A safety culture is not a no-blame culture for any action taken. It refers to human error and not at risk and reckless behavior.
This is such a difficult subject. As a retired RN, with many decades of direct patient care, few of get through without making a med error. Fortunately for my clients, no harm was caused. I can say I remember everyone and what I did wrong. Though I reported each one anonymously, as required by my employer, I always felt more should have been done.
I understand the reason for anonymity, I also can’t help but believe there are even more med errors that go unreported. Scary thought when you read the statistics of annual hospital med errors.
So if we never own up to these errors , how do we begin to improve medication administration practice. My last job I saw too many staff circumvent the med administration procedure and we had many “fail safe” protocols already in place. ( Pyxis meditation, bar coding, fingerprint entry into med room and Pyxis machine, epic computer recording system.)
And how do we compensate those clients who have been the recipient of this injury as currently families must retain legal aid for any compensation.
I don’t necessarily believe that the current system we have improves med errors as we continue to have astronomical numbers.
Would love to be part of the solution. Its unfortunate that the healthcare system doesn’t employ retired staff to address some of these issues.
We must all show our support for her as it could have been any of us. If she wasnt honest, trustworthy and conscientious- she would not have incriminated herself.
Until the wording of the rules/regulations/laws (AKA: standards) that govern our licensure are changed, no amount of woulda-coulda-shouldas will help. This nurse did the right thing and paid the price for her transparency because of these standards. It is not the courts’ opinion or judgment that may send this nurse to prison; it is the wording in these standards that allow anyone who knows how to access each state’s Board of Nursing website, to file a complaint. And it does not matter if the complaint is false or unfounded; it will be investigated. It is this current ‘state of affairs’ that yields years…decades…of cover-ups, under-reported medication errors. and worse. Because of the wording in the documents that govern our Scope of Practice. Not the laws of our country, but the documents that we as nurses are held accountable to: Scope of Practice. It is THOSE words that need changed, thereby ensuring more safety.
I wish there were a petition to sign to encourage the judge to give her the minimum sentence possible.
I’ve been hearing for years that I should report med errors and nothing will happen. This proves we need to go back to hiding errors and covering up. Patients will die because nurses are afraid to report errors and problems in the system will not be fixed.
Recently retired from 22 years of critical care, I hope the nurse in question is not imprisoned. This unfortunate event was, at least partly, a systems error. Fear of retribution is alive and well, and let’s not fuel it. Human error will always exist. Nursing today is extremely complex and demanding, much more so than it was 40 years ago when I first practiced. Imprisoning this nurse will benefit no one. Let’s improve the systems to reduce these types of errors.
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There but for the grace of God go I. And every other nurse I know.
Though I am concerned regarding criminal charges, at the same time, the definition of a safety culture acknowledges that when human error occurs, the system should be analyzed to prevent similar actions occurring in the future. However, there is recognition that when there is reckless behavior, some form of disciplinary action should be taken. I have read the actions taken to override (it took quite a few steps to obtain the wrong drug) and in my estimation the behavior was reckless. There was also a system failure in that the medication should not have been available at all. But ultimately, the nurse becomes the final safety net because it is at the point of administration. A safety culture is not a no-blame culture for any action taken. It refers to human error and not at risk and reckless behavior.
This is such a difficult subject. As a retired RN, with many decades of direct patient care, few of get through without making a med error. Fortunately for my clients, no harm was caused. I can say I remember everyone and what I did wrong. Though I reported each one anonymously, as required by my employer, I always felt more should have been done.
I understand the reason for anonymity, I also can’t help but believe there are even more med errors that go unreported. Scary thought when you read the statistics of annual hospital med errors.
So if we never own up to these errors , how do we begin to improve medication administration practice. My last job I saw too many staff circumvent the med administration procedure and we had many “fail safe” protocols already in place. ( Pyxis meditation, bar coding, fingerprint entry into med room and Pyxis machine, epic computer recording system.)
And how do we compensate those clients who have been the recipient of this injury as currently families must retain legal aid for any compensation.
I don’t necessarily believe that the current system we have improves med errors as we continue to have astronomical numbers.
Would love to be part of the solution. Its unfortunate that the healthcare system doesn’t employ retired staff to address some of these issues.
We must all show our support for her as it could have been any of us. If she wasnt honest, trustworthy and conscientious- she would not have incriminated herself.
Until the wording of the rules/regulations/laws (AKA: standards) that govern our licensure are changed, no amount of woulda-coulda-shouldas will help. This nurse did the right thing and paid the price for her transparency because of these standards. It is not the courts’ opinion or judgment that may send this nurse to prison; it is the wording in these standards that allow anyone who knows how to access each state’s Board of Nursing website, to file a complaint. And it does not matter if the complaint is false or unfounded; it will be investigated. It is this current ‘state of affairs’ that yields years…decades…of cover-ups, under-reported medication errors. and worse. Because of the wording in the documents that govern our Scope of Practice. Not the laws of our country, but the documents that we as nurses are held accountable to: Scope of Practice. It is THOSE words that need changed, thereby ensuring more safety.
I wish there were a petition to sign to encourage the judge to give her the minimum sentence possible.
I’ve been hearing for years that I should report med errors and nothing will happen. This proves we need to go back to hiding errors and covering up. Patients will die because nurses are afraid to report errors and problems in the system will not be fixed.
Recently retired from 22 years of critical care, I hope the nurse in question is not imprisoned. This unfortunate event was, at least partly, a systems error. Fear of retribution is alive and well, and let’s not fuel it. Human error will always exist. Nursing today is extremely complex and demanding, much more so than it was 40 years ago when I first practiced. Imprisoning this nurse will benefit no one. Let’s improve the systems to reduce these types of errors.