So much has already been written and said about RaDonda Vaught. She was the nurse convicted in Tennessee. The conviction was because she gave the wrong medication that caused a patient’s death. In this blog, we have already explored the implications of this case to the profession. We have also analyzed the systemic factors that may have contributed to the series of mistakes. However, isn’t it worth reflecting on the five reasons why it could also happen to us?

Reason No. 1 – To Err is Human

This is a universal truth that nobody can refute. All of us, without exceptions, have made mistakes whether intentional or not. It is inherent in humans to make mistakes because none of us is perfect.

In healthcare, the Institute of Medicine published a book entitled “To Err is Human: Building a Safer Health System.” Part of the third chapter distinguishes the difference between slips or lapses and mistakes. If a nurse does something but it was not the intended action, it is either a slip or a lapse. On the other hand, a mistake is performing the action but it fails to elicit its intended result.

Slips, lapses, and mistakes are errors that may potentially cause adverse effects on the patients. In 1990, James Reason defined an error as:

failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance. 

A slip could be something as simple as forgetting to open the intravenous (IV) tubing roller clamp.  Maybe, it is entering 1000ml/hr as the IV rate instead of 100ml/hr.

Was either of them intended? Most probably not. Nevertheless, the patient could be under or overmedicated, depending on the administered infusion.

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Reason No. 2 – Floating to Another Unit

Floating is a cost-effective way for institutions to address patient needs according to number and/or acuity. Instead of augmenting staffing needs with the costly agency or travel nurses, in-house nurses take turns to staff units that require help for the shift. While it helps hospitals with costs, it can be risky in terms of patient safety.

There are two schools of thought as far as nurses are concerned when it comes to floating:

A. Positive Experience

Some nurses welcome floating as a learning opportunity. They feel comfortable working in areas as long as it is within their scope of practice (e.g. a Telemetry nurse floating to a Medical-Surgical Unit). They look at it as a way of expanding their skills and knowledge in taking care of a patient population that may be different than the ones they are familiar with.

B. Negative Experience

It is not an exaggeration to state that floating causes anxiety to most nurses. Even experienced ones dread going to a unit that is not within their comfort zones (e.g. a Pediatric nurse working as a “runner” [gathering the needed supplies] in an adult Covid 19 unit). Being not familiar with where the supplies are or the unit-specific culture/practice adds up to that anxiety level. So much so that this causes uneasiness and dissatisfaction on the part of the floating nurses.

That heightened anxiety, in turn, causes nurses to have slips, lapses, or mistakes. They may even question their own abilities and strengths if they are unable to address patients’ questions. What more if the staff in the unit are not as welcoming or accommodating?

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Reason No. 3 – Unfamiliarity with the Workflow

Closely tied with the floating situation is the nurse’s unfamiliarity with the workflow or the unit culture. Even with proper orientation, it is unrealistic to expect floating nurses to know all the workflows of the units they float to.

Some may reiterate the fact that there are not too many variances in workflow among similar units. That may be true, but it is still not the nurse’s comfort zone. What if the nurse’s unit has resident physicians and the one he or she is floating to does not? If because of that he or she is unaccustomed to calling an attending, who should do that for him or her? This may seem small, but there are so many caveats when it comes to differences in workflows.

Needless to say, an already anxious nurse who is not familiar with the workflow is a ticking time bomb!. 

Reason No. 4 – Distraction

Distractions are everywhere in healthcare. It could be in the call lights from patients’ rooms, alarms from the cardiovascular monitors, phone calls, overhead announcements over the public announcement system, and yes, even questions from colleagues. In Vaught’s case, she had an orientee that day.

As nurses, we have been so immuned with all these distractions so we tend to tune them all out. It will be beneficial if tuning them out makes us pay closer attention to the task at hand, but sometimes it does not. We tend to be on autopilot when we need a temporary mental break from the distractions and the increased anxieties they bring.

A study conducted in Australia concluded that distractions caused a 12.7% increase in medication error risk. The same research also found that the rate tripled when the clinician is interrupted or distracted six times between preparation and administration of drugs.

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Reason No. 5 – Mental and Physical Fatigue

Have you ever driven a car and realized that you already passed your destination? I have, and not only once, if I may add. I am not proud of it, and yes, it is dangerous. However, this is what mental and physical fatigue can do to you.

Twelve-hour shifts can be both physically and mentally draining. Sometimes it may even cause some sleep deprivation. Cumulative sleep deprivation may lead to burnout and eventually patient safety.

The nurses’ resilience has upheld us all these years. Twelve, even 16-hour shifts, are like nothing to us. The unit is short and help is needed? We sign up for overtime. Have we even stopped and evaluated at what expense are we doing all of these?

Ways to Mitigate Errors in Practice

Obviously, there are other human factors that may predispose us to commit mistakes at work. It is especially sad if those errors result in adverse effects on our patients or even on our own psyche and self-confidence. Having been able to identify some of the common ones, what are some ways to mitigate and prevent those errors from happening?

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Personal Accountability

1. Pay attention to details. Use a high-reliability organization tool such as STAR (Stop. Think. Act. Review.)
2. Self-report errors to appropriate leaders (e.g. charge nurse, manager, etc.). Ask for directions on what to do for the next step.
3. Talk to appropriate people to help get over the guilt of making the mistake. Attend debrief sessions. Ask if the organization offers psychological help.
4. Advocate for one’s self. Ask for additional training if needed prior to being floated to another unit.
5. Ask questions. Identify resources (e.g. buddy nurse or charge nurse) when floating.
6. Set realistic goals and expectations with your and the other unit’s leaders when floating (e.g. capabilities and limitations).
7. Review responsibilities when entrusted with an orientee.
8. Don’t cut corners and save time by doing workarounds.
9. Learn to say “NO!” Don’t feel guilty if you are unable to help out your unit when short-staffed.
10. Take breaks – do something that enriches you. Go on vacation, watch a show…anything that fills you up. A refreshed body, mind, and soul function better at work.

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Organizational Role

1. Develop Just Culture and a Culture of Safety.
2. Hardwire voluntary reporting systems by reiterating that reports are used to improve processes that promote patient and clinician safety.
3. Involve frontline staff with root cause analysis cases for near misses or good catches.
4. Debrief and provide mental and emotional support to frontline staff when mistakes are caught and mitigated in time.
5. Conduct regular cross-training amongst staff of like units prior to floating. Reevaluate the need to retrain, as needed.
6. Identify point persons as resources in each unit whenever a nurse floats. Also, provide a “cheat sheet” or a worklist for floating nurses on the usual tasks being done in that unit.
7. Provide opportunities for those who floated to give their honest feedback on the floating experience.
8. Evaluate alarm fatigue and develop ways to minimize them to limit distraction.
9. Preceptors should have a lighter workload so that they can appropriately guide their orientees.
10. Establish “do not disturb” zones like in the medication room or where the automatic dispensing cabinet is located and at the patients’ bedsides.

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Final Words

As we have established in the Nurse Convicted trilogy, various reasons can cause a mistake to happen in healthcare. It also takes a village and multifaceted approaches to prevent them from happening again. More than the dollar costs, adverse effects can be fatal to the patient and career destructive as in the Vaught case. It can also have a reverberating effect that can be felt for many years to come. We are already bursting at the seams as a profession, we cannot afford another blow!

It is therefore to the best interest of nurses, all clinicians, and more importantly of the patients that we continue the dialogue on how to improve patient safety. Are you ready to take on that torch?