Guilty
We make mistakes. Guilty.
The recent court case finding a nurse guilty of criminal negligence (murder) for a medication error just stands as more proof that nurses are on their own.
Medication errors are fully owned by the person administering the medication. There is no excuse for giving a patient the wrong medication. We have the five rights (right patient, right medication, right time, right dose, right route) for a reason. We have the medication dispensing machines; medication and patient scanning for a reason. We have double checks (two nurses) for some medications for a reason. Safety. These checks are set up to keep patients safe. They work, for the most part.
But what happens when they don’t? What happens when one part of the series of checks is broken, down-time, or turned off? What happens when a nurse skips a step?
A patient can be killed. It is horrible and heart-wrenching. Families are devastated. There is no one to blame at the end of the day except the one giving a fatal dose of anything. You do not hand over, inject, or administer any medications without knowing it is the correct one. Period. In an ideal world that is how it should be and how it is.
In the real world, it is very different. Emergencies call for over-riding all of the safety measures put into place. Things that happen in the real world are far different than what happens in a text book. If an accident happens it isn’t willful, or intentional, it’s an ACCIDENT.
Nurses are being asked to do so much more these days. If there are no CNA’s or techs, the nurses do their jobs too; if there are housekeeping shortages, the nurses clean rooms and take out trashes; if there are fewer dietary staff members, the nurses pick up the slack with trays etc; if therapy can’t come by today the nurses do the walks and transfers; if RT’s are in short-supply, nursing does the breathing treatments. When there are nursing shortages, the nurses just take more patients and add to their workloads. No other department picks up any of the nurses’ duties. If a nurse takes a short-cut and gives a medication without scanning it because the scanner is broken but she does not have the time to find one that is working, it’s understandable.
There are two sides to every issue. There is the side that says a nurse must follow every rule to the letter and never deviate. There is the side of real-world life in the hospital and some steps are going to get missed some days because there aren’t enough people, supplies, or working equipment to make it perfect.
I can very easily sit in judgement of a nurse who gives the wrong medication. I don’t care if they look and sound alike, you better know what each of them is and you better know which one you are to give. If you don’t, you stop and go find someone who does.
I can very easily see how a medication error happens when you are so busy and you assume you grabbed the right one, you will scan it later and it’s too late.
The lesson in all of this is two-fold. Nurse: don’t work if your system isn’t working. If the medication safety checks are down for the hour or the day, then so are you. Someone’s life may depend on it. If we have learned nothing else, we have learned that administrators and hospitals do not have our backs. They will fling arrows into us as quickly as they can to cover their asses. An unintentional error can be a horrible life-altering, heart-wrenching, family changing, career ending event and as a nurse, if you made the error, you are on your own.
Secondly, take your time, slow down, do no harm. That nurse’s heart must have stopped for a moment when her patient’s did for eternity. No nurse wants to make that mistake. If your practice is sloppy, if it’s lazy; if it’s “blamey” if it’s risky, stop. Go back to the basics, do what you can with what you have and do it well. Do it right.
There is no good ending to what this story does to a nurse’s soul.
Learn what you can from it.
