Several nurse colleagues and I were having lunch together and sharing stories of work-related events that made a lasting impact on us. I was astounded to learn that an action I took about 10 years ago was the reason one of my colleagues was still a nurse. What did I do that was so career altering? I took her to breakfast.
Now a successful nursing leader, she described an event when she made a medication error involving a complex I.V. infusion. At the time, she was a brand-new nurse who had just finished a 6-month nursing internship program. Although the patient suffered no harm and she took all of the correct steps to immediately notify the physician and other appropriate parties, the very act of making a medication error rocked her world. At that moment she decided that she needed to resign because nursing was not the right career choice for her.
My response was not at all what she expected. She admitted feeling incredibly intimidated to join me for breakfast, but instead of treating her punitively for the error, I thanked her for disclosing it rapidly and giving us an opportunity to address several system issues that likely contributed to the miscalculation. Her error ultimately served as a catalyst for making improvements to our smart infusion pump technology and establishing pharmacist presence in the ED as a patient safety initiative. This nurse not only survived this situation and stayed on to learn and grow in her nursing career, but also pursued a leadership path to inspire others.
Given the heavy demands imposed in today's nursing work settings and the complexities of patient care, making an error in a punitive environment can trigger a personal and professional breaking point. How the error is handled after the fact is key to the outcome. Typical healthcare “culture of safety” surveys ask employees to rate whether or not they believe errors are held against them. A punitive culture is well known to inhibit self-disclosure and overall error reporting; it does not promote a climate of transparency so that safety issues can be readily identified and rectified. It also leads to the loss of good people.
Nursing is a tough job. Each of us holds the power to change our culture to one of mutual support, integrity, and system-oriented action instead of blame and shame.
Until next time,
LINDA LASKOWSKI-JONES, MS, APRN, ACNS-BC, CEN, NEA-BC, FAWM, FAAN