Growth through Hardship
Medical errors. They will unfortunately affect everyone at some point in their lives whether it causes a big problem or not. Some errors you might not even be made aware happened to you at all. Even scarier, the medical professional might also not be aware of their error that induced the harm at the time.
The medical profession is one that is primarily compromised of humans- I say primarily because there are so many new technologies being developed with the use of artificial intelligence- but it still remains a profession of human beings, with human feelings, that make human mistakes.
I vividly recall the first error that I made as a nurse that impacted a patient. It is something I will never forget because it made me question my entire nursing career from one event. This is the part of these events that is often overlooked, which is the secondary harm that is caused to the nursing staff who cause the error (Alberts et al., 2022). The guilt, shame, embarrassment, and fear that you might cause harm to someone else in the future is an emotional roller coaster.
As unfortunate as it is, we do make errors, but if we do not learn or change our actions, that is where the real problem lies. As a healthcare provider, you never forget your mistakes, especially the ones that impact the people that we care for. Every nurse that I personally know has made a mistake in their career, some are just higher stakes than others.
I loved this quote that was shared with us this week and reflected on it for awhile. Mistakes do teach us a lot, but we have to listen to the lesson associated with it.
While the statistics on medical errors seem shockingly high, being in the medical profession I know that is probably an understatement of the actual number of errors that truly occur.
For example, when discussing error reporting just within my current set of peers, we discussed many reasons that errors may not be reported:
🚫 some errors seem 'too small' to report
🚫 it did not actually reach the patient, also called a 'near-miss' event
🚫 nurse assignment/task overload
🚫 difficulty with error reporting site
🚫 fear of getting reprimanded
As I look at this list, it is very eye-opening. Maybe if more of the errors that were 'too small' or related to 'near-miss' events were reported, it would actually improve the system errors in the processes that eventually lead to big problems and sentinel events. More of an emphasis should be placed on reporting all types of events in order to create a better culture of safety.
There are also a variety of errors that can take place while working, such as the ones that might be made when learning a new skill. If you aren't stretching your potential, you aren't growing as an individual and bettering yourself. However, it must be recognized that while you are growing, the potential for errors does increase, therefore the use of safety nets, such as mentors and preceptors, also needs to increase to prevent any serious errors (Alberts et al., 2022).
"About 90% of the average leader's responsibilities involve dealing with human behavior and human interaction" (Alerts et al., 2022). I truly had not thought about this until I focused my attention on my direct manager's position for just one day and realized how many times I heard the phrase, "let's have the manager deal with this." I have worked in many different healthcare settings and have picked up on a few traits of good and bad leaders when dealing with a conflict to determine how I would choose to manage a conflict.
Good Leader Characteristics:
-active listener, being engaged in the moment
-empathy
-not jumping to conclusions and staying open-minded
-facilitating open conversation between team members
Bad Leader Characteristics:
- placing blame
-closed off body language
-cutting you off with a response before your thought is complete
- closed minded, jumping to conclusions
-turning team members against each other
Complexity in Healthcare
Staffing ratios in the healthcare profession are often just simple numbers to those not actively involved in the numbers. To upper management it can seem like simple math. Three nurses take five patients a piece so we can take fifteen patients. 3 x 5 = 15... easy, right? WRONG!
Numbers in healthcare are COMPLEX!! There are several factors to consider and so many moving parts! To name a few that aren't always taken into account...
-agency/travel nurses, float staff
-years of experience, skill deficits
-problems in home life, lack of sleep
- acuity of patients
-change in status during the shift
-high fall risk, isolation, confusion
-new admissions, discharges, recent surgery
Pat Ebright, 2010, really hits the nail on the head with her discussion about the nursing profession using the complex adaptive system theory model. Ebright also goes on to discuss multiple aspects of nursing care that really resonated with me as I did not realize there was specific terminology for these acts that I tend to do as a nurse without knowing it! It is fortunate that the nursing school curriculums are being somewhat revamped to include more than just technical skills (although that is what was the most fun for students!) 😊
- Stacking- These are the mental checklists that we do as nurses. It's how we start our day prioritizing our tasks and what needs to be accomplished and how it gets re-prioritized based off of the days events. I am the queen of checklists and know that this is something that I definitely utilize and have had to learn the skills to determine what is important and needs two be shifted up and what things might need to fall off of the list all together! Doing that has always been a struggle for me personally, but with the increasing demands in today's world of healthcare it has become a necessity.
- Peeking- This actually goes together with stacking as this is a state of constant observation. Nurses pick up on cues from their environment to determine what needs to be done next and how to order this prioritization. This looks different through the eyes of a new nurse and an experienced nurse and these skills are something that are learned over time through experience.
Ebright, 2010, also mentioned a popular nursing theory outlined by Patricia Benner regarding nursing evolution from a novice to expert and how it ties into these skills. A nursing leader should be aware of where the staff that they are managing are at on this pyramid with an attempt to ensure there is never a large cluster of only novice nurses as the risk for errors increases in that set of circumstances.
Interruption Awareness
Nurses and other healthcare professionals are interrupted during a task countless times during just one shift. This can turn even the simplest task into one of complexity. I found this workshop on interruptions in the healthcare profession a good portrayal of the overwhelming nature of nursing on most shifts.
So how can we overcome some of these interruptions? There are several different tactics that can be used. I will provide a few examples that seemed to at least contribute to the decrease in interruptions during times of higher risk such as medication dispensing and placing patient orders.
*Red rugs located in areas where high focus is needed around the unit. While a nurse was on this rug they were not to be interacted with, or interrupted in their thoughts, until stepping off of the rug to allow for complete concentration.
*When scheduling patients for procedures there is a red flashing light to alert others to wait until this light is off to approach for questions or scheduling another patient so there is to be only one patient being focused on at a given time.
* Computerized charting system safeguards which includes a maximum number of patient charts that can be opened at one time. This ensures that not more than four charts can be opened at one time and there is a hard stop is trying to open more than four charts. I know that four charts seems like a lot of people to have open at once but it actually happens quite often as you are constantly interrupted! (See video above).
References
Albert, N. M., Pappas, S. H., Porter-O’Grady, & Malloch, K. (2022). Quantum Leadership (6th ed.). Jones & Bartlett Learning
mentorsgallery. (2010, Februray 2). Pat Ebright - Complex Adaptive System Theory. [Video]. YouTube. https://www.youtube.com/watch?v=Dv1BP9BGPWg
mentorsgallery. (2010a, January 29). Pat Ebright - Stacking [Video]. YouTube. https://www.youtube.com/watch?v=IVHbty3iI9k
Comments
Post a Comment