“Before we go blaming anyone, let’s sit down and try to figure out what happened. There are certainly some unusual circumstances in place today. Your game was cancelled unexpectedly and the playroom is out of bounds. Still, we have household rules in place for the safety and best interests of everyone in this family. First, the living room is not a play area and second, we don’t use outside sports equipment in the house. Soft foam balls and pucks are used in the playroom. You were wrong to decide not to follow the house rules. Any time you think rules do not need to be followed, discuss it with your mother or me first. You also miscalculated how hard you were throwing and how to catch the ball. I also realize that although your mother usually supervises you in the house, she was busy with other work. I should have covered for her by supervising you myself.”

At supper that night, the whole family talked about the near miss earlier in the day and decided how to make sure it didn’t happen again.

If we change our focus to a hospital setting, we will find it is not unlike this family. In a hospital, a group of individuals work together for the safety and best interests of everyone. Like anyone else, workers can make a mistake. Unfortunately, errors that go uncorrected may eventually cause harm. Accidents happen, so the system has to be designed to catch them before they can harm patients.

The student nurse was excited about working on the labour and delivery floor. She loved babies and could see making this her job once she graduated. The mother she was working with was doing well, but felt sick to her stomach. Hopefully she would feel better soon. The nurse got the prescribed anti-nausea medication for the mother, and dutifully showed the label of the medication to her supervising nurse before adding it to the IV line.
“Wait!” her supervisor said. “This is diphenhydramine, an allergy drug, not dimenhydrinate, the drug you wanted to treat this patient’s nausea.”

In the past, when errors were reported it was normal to go looking for the person responsible. Often, one person took the blame for the event. Now we recognize that a number of issues can affect each event and rarely is one person totally responsible. This change is called a culture of patient safety.

Hospitals are changing in the way mistakes and accidents are reviewed. Events are assessed from a patient safety and system design approach. The health care team evaluates any near misses, events that might have resulted in harm to a patient. Without blaming anyone, they discuss circumstances that led to the situation, identify problems and put systems in place to ensure mistakes do not happen again. Each team member’s opinion is valued and respected. Nurses, doctors, administrators, cleaning staff and others may all be involved in these discussions.

In the hospital, staff work as a team to help families have the safest care possible while respecting personal wishes and desires. Since systems are in place to help maintain a safe environment, what kind of errors may occur?

Unusual Circumstances

Just as in the family’s situation, circumstances may be unusual. Hospital maintenance might interrupt the flow of water or telephone lines for a brief period of time. Someone’s pager may not be working properly. A water pipe may break in the pharmacy. While the possibilities are endless, most hospitals have backup systems in place to prevent problems related to unusual situations. By learning from past experiences, backup systems can be improved.

Standards

Much of the care provided in hospitals is routine. Written protocols guide staff for routine care. Protocols might include how to set up and monitor an intravenous (IV) line, monitor a baby’s heart rate during labour, give blood transfusions, and check drugs and medications given to patients. Sometimes, the standard may not be the best way to manage a specific situation. In that case, discussion and written notes can be used to explain why a standard was not followed. These protocols are reviewed regularly and updated as times change.

Errors in Judgment

Nurses and doctors working in a hospital must judge how to handle events as they arise. When assessing a patient in emergency complaining of abdominal pain, one might detect signs suggesting surgery while another decides that the pain is related to a flu-like illness. There is room for differing opinions, but any member of the team must be able to discuss why they do not agree with the judgment of another. Since everyone in the hospital has different levels of experience, discussions improve everyone’s knowledge and skill.

Discussion

By far, our best tool in avoiding error is communication. Unfortunately, miscommunication often results in errors. Doctors may not be heard clearly from behind their masks, medical terms may be misunderstood and short forms that have more than one meaning may be used. Patients are often embarrassed to admit they did not understand what they were told or a language barrier may exist. Whenever communication is not clear, it is important to make sure there is no misunderstanding.

Nurses and doctors write down assessments, opinions and plans regularly to help eliminate communication errors. As computers become more common in health care, errors from poor handwriting are eliminated. Whenever possible, medication orders are written, not just said to someone. As shifts change and new staff members come on duty, detailed information about a patient’s history and time in hospital is discussed before the change occurs.

Communication also includes the way that information is given and received. Is everyone free to point out when they are concerned about an issue on the unit? Are all members of the team respected for their knowledge and skill? When a near miss occurs, is it discussed by everyone close to the time it occurred, so the event is still clear in everyone’s mind?

It may seem surprising that patients have a responsibility in this new culture as well. If a patient is aware of a miscommunication or incident that could result in personal harm, they must let one of their care providers know. This does not mean they have to complain. Rather, they are helping to improve hospital care for everyone. They are part of the team.

Miscalculation

Medications are usually ordered by weight, for example, 50 g of drug A. Drug A may come in a vial of 100 g and need to be diluted in a bag of fluid of 50 mL but given at a rate of 10 mg per minute. It is easy to see that some calculations need to be performed to make sure the patient gets the right dose of the drug. Also, many drugs have similar packaging or names that can be confused. Hospitals have systems in place so that nurses not only get someone to check their calculations, but also have the label checked to make sure they have the right drug before it is given to the patient. With commonly used drugs, the pharmacy will often premix them to decrease the chance of calculation error.

Workload

Activity in hospitals can be hard to predict. Very little happens on one day, while on another there might be a major accident on a nearby highway. Nurses may be off sick and doctors may be trying to deal with a busy office. Students may be working over 24 hours in a row. Staff on the unit must be willing to work as a team at all times, covering for each other when things are busy, doing jobs they would not normally do just because they must get done. If the workload is always too heavy, changes to staffing are needed.

Patient Safety Culture

In a patient safety culture, every team member has a responsibility to report anything that could possibly harm patients. Concerns are addressed promptly without assigning blame. Possible solutions are explored and new steps are introduced to avoid future problems. If a patient is involved, even if no harm was done, they are informed, asked for input and told what steps are being taken to prevent the same event from happening again.

So what happened with our student nurse and her near medication error?

The nurse and her supervisor returned to the medication room and saw that since the drugs were in alphabetical order on the shelf, the two easily confused medications were right next to each other. They immediately made a written recommendation to the unit manager to separate the two drugs and add the commonly used name in brackets to the shelf label to help avoid confusion in the future. Another good catch!

Yes, the student nurse could see herself working in this place where everyone co-operated so effectively together.

Patient Safety in the Hospital A team approach to avoiding errors