Essay 5: Open reporting of errors
You are the unit supervisor of a medical-surgical unit. Jane is an RN on your unit. She graduated 3 years ago from nursing school and has made a number of small errors in the past few months, all of which she voluntarily reported. These errors included things like missing medications, giving medications late, and on one occasion, giving medications to the wrong patient No apparent harm has occurred to her patients as a result of these errors and on each occasion, Jane has responded to your coaching efforts with an assertion that she will be more attentive and careful in the future. Today however, Jane came to your office to admitted that she flushed a patient’s iV line with 10,000 units of heparin rather than with the 100 units that was ordered. The vials looked similar and she failed to notice the dosing on the label. Jane reported the error to the patient’s physician and filled out the adverse incident report form required by the hospital on all medication errors. At this point, the patient is demonstrating no ill effects from the overdosing but will need to be closely monitored for the next 24 hours.
You recognize that Jane’s pattern of repetitive medication errors is placing patients at risk. You have some reservations about dealing with Jane in a punitive way since she openly reports the errors she makes and because none of her errors until today ad really jeopardized patient safety. You are also aware that you have an obligation to make sure that the staff caring for your patients are competent and that patients are protected from harm. You are also attempting to establish a unit culture that encourages open reporting, not “shame and blame” so you are aware that your staff are watching closely how you will respond to yet another error on Jane’s part. You know that Jane’s habit of making the same medication mistakes over and over again puts patients at risk. You’re not sure if you want to punish Jane because she admits when she makes mistakes and because, until today, none of her mistakes really put patient safety at risk. You also know that you have a duty to make sure that the people who care for your patients are skilled and that your patients are safe. You are also trying to create a unit culture that encourages open reporting and not “shame and blame.” Because of this, you know that your staff is closely watching how you handle Jane’s latest mistake.
Please answer the following questions on how you would handle the situation (5 points each)
#1. What will you do to address this error as well as the errors Jane has made in the past few months?
#2. What options are available to you?
#3. What obligations do you have to Jane, to the organization, and to the patients on your unit?
#4. How will you create a culture that encourages the open reporting of errors and yet protects patients from potentially unsafe practitioners?