Realizing That A True Blameless Culture Corrects The System and Increases Medication Error Reporting

by | Jul 1, 2022 | Career, Network, Professional Skills, Workplace Matters

     A while ago, there was a news story about a medication error.  It seems a nurse gave a patient the wrong medication.  The patient died.  After a recent court battle, the nurse got three-years of probation.

     People make mistakes.  Administrations and their hospitals know that they do.  Yet, quite often, they make the people in the facility the scapegoat for medication errors.

     In this case, it was the nurse who was made to suffer from the medication error.  Yes, the nurse was the one who gave the wrong medication which led to the medication error.  But consider the following:


Hiring Inadequate Staff

     When my wife was a patient in the hospital, there were 24 patients on her floor.  During the day shift, there were 4 registered nurses (RNs) and 3 patient care technicians (PCTs). A PCT was a non-licensed worker, who completed some kind of nursing program in an accredited school or college.  Thus, there was 1 RN for every 6 patients.

     During the afternoon shift, there were 3 RNs and 3 PCTs.  That was 1 RN for every 8 patients.  During the night shift, there were 2 RNs and 2 PCTs.  That was 1 RN for every 12 patients.

     I wasn’t too impressed by the pretty bulletin boards on the unit that stressed exceptional patient care.  Or the data showing that call bells were answered in the first two minutes (they weren’t!). But who decided that 1 RN for every 6, 8, or 12 patients was proper staffing?  I didn’t think so with everything that they had to do!

     I don’t know why administrators, hospital vice-presidents, and high-ranking nursing personnel allow such minimal staffing levels to exist in hospitals.  My wife got exceptional patient care, but there were times that we just had to wait because the RNs were busy doing other things.

     Furthermore, the poor staffing levels occurred in every unit from Monday through Friday.  On weekends, it was even worse— the RN-to-patient ratios were terrible.

     This lack of adequate staffing causes stress, burnout, and mistakes.  Hospitals should hire more RNs and increase the number of RNs on each unit.  But they don’t.  Thus, when nurses make a medication error, it’s their fault! 


Choosing The Wrong Technology

     In the early 2000s, most pharmacies and their hospitals were implementing medication systems in order to increase efficiency, improve patient care, and ensure safety.  There were some very good systems on the market.  These systems made it easier for 1) physicians to write and send medication orders, 2) pharmacies to fill the medication orders, and 3) nurses to administer the medications to the patient.

     As I said, there were some very good systems on the market.  However, these systems were all quite expensive.

     If a hospital did not wish to pay for an expensive system, there were other systems available.  These other systems were less expensive primarily since they did not have all the features that the better systems had.

     There were also some mediocre systems on the market.  Many of these systems lacked key items that many of the good systems had.  Some cut corners and were a poor imitations of the better systems.  But they were less expensive.  So hospitals and their administrators gravitated to these systems.  Thus, quality was sometimes sacrificed for dollars.  What’s more, nurses, physicians, pharmacy, and others had to live with and use these inferior systems on a daily basis.  They had to do without the better features that were sometimes found on a better system.

     Many times, my staff and I worked with systems that lacked the necessary features that better systems had.  We were fortunate.  One of my pharmacists was an IT specialist.  He was a pharmacist and quite knowledgeable about computers and various systems.  He could reprogram any computer or system to meet our needs.  He devised many workarounds or alternative programs to bypass the system, in order to perform the jobs that needed to be done.

     I was all for systems that increased efficiency and produced added safety.  But I wasn’t (nor was my staff) willing to change our work procedures in order to make the computer happy.

     Quite often, my pharmacy was not given any choice as to what systems were installed in the pharmacy department.  We never had any choice in the matter.  No one ever asked us.  Yet, we were the ones that worked with it each and every day.  

     Furthermore, we were expected to change our procedures, “because the computer didn’t do it our way.”  Thus, we had to develop overrides, in order to make the computer happy. Thereby allowing us to do our work in the way that we wanted to.

     I was certain that nurses, physicians, and others who used the system devised overrides so that they could work as desired.

     My pharmacy created these overrides and workarounds 1) to compensate for the features that the systems lacked, and 2) to sync the system with our workflow procedures.  Had the hospital purchased a better system, these overrides would not have been necessary.  And perhaps any medication errors that resulted from these overrides would not have occurred.


Ignoring Workers’ Feedback

     Prior to putting in a new system in a nursing unit, the hospital established a nursing task force.  The task force’s goal was to review the systems available within a given price range and provide adequate feedback.  The task force did its job.  They examined the various systems, listed the features that they felt were most essential and made their recommendations.

     The administrators thanked the task force.  Then, they promptly ignored their feedback and recommendations.  The administrators then chose the system that they wanted all along.  They chose the least expensive system.  The system is without the key features recommended by the nursing task force.  This was a big mistake.

     I have often felt that people like to be empowered.  They like to have input in projects and equipment that they will use on a daily basis.  It is unwise to ask them for suggestions, and then do what you want.  Because as a result, you’ve lost them!  They won’t be involved this time or any time in the future. You’ll never be able to ask for feedback again because they’ll ignore you. 

     Instead, you’ll hear: “Last time they asked for suggestions and then they did what they wanted.  Why should we offer suggestions this time?”

     I always knew that hospitals (like most businesses) watched their expenses.  Hospitals watched their costs and monitored their expenses.  But sometimes “you get what you pay for.”  And those in power don’t always know what’s happening in the nursing unit or pharmacy.

     The less expensive system was unrealistic.  It did not take into consideration how nurses did things on a daily basis.

     This system was anchored behind the nursing station, far from the individual patient rooms.  In order to get medications for a particular patient, the nurses were expected to enter several keystrokes on a multitude of computer screens.   After obtaining the medications for the patient, they were expected to: 1) go to the patient’s room, 2) administer the medications, and 3) return to the computer to repeat the process in order to get the next patient’s medications.

     Therefore, if a nurse had 6-12 patients, the system required the nurse to go back and forth from the nurse’s station to the patient’s room 6-12 times!  So what did the nurses do?  They created a workaround where they would obtain 6-12 patients’ medications.  They placed all the medications in a container and brought the container (filled with medications) to each patient’s room. 

     Did this create a potential for additional medication errors?  Yes. But that was the problem with this system.  It caused an unrealistic expectation where it made the nurses go back and forth from the system to each patient room. These unnecessary trips forced staff members to create overrides in order to compensate for unrealistic workflows and missing features of the system.


Encouraging Medication Error Reporting

     Hospitals want to encourage medication error reporting.   They want medication errors reported so that their workers can learn from others’ mistakes.  What’s more, if medication errors are reported, individual hospitals can usually put safeguards to prevent that particular error from occurring in their facility.

     My hospital claimed they had a non-punitive policy when it came to medication errors.  They wanted to encourage their staff to report medication errors without fear of retribution.  After all, most staff members would not report a medication error if they or someone else were to suffer.

     Thus, my hospital established a process called “just culture”.   It encouraged medication error reporting while treating medication errors as if they were failures in the system rather than personal failures.

     Until the first medication error occurred. One of my pharmacists reported that he had made a medication error over six months ago.  At that time, he was the pharmacist responsible for providing a chemotherapy medication for one of the clinic patients.  He stated that he accidentally filled an order for “Taxol” with the medication “Taxotere”.  He was very sorry.

     Although this was a medication error: 1) the medication error happened over six months ago, 2) no repercussions were ever suffered by the patient, and 3) no one would have even known that the medication error happened if the pharmacist involved hadn’t reported it.

     After two days of meetings between the risk manager, the Human Resources vice-president, and myself (the pharmacy manager), the pharmacist was suspended for three days without pay.  So much the hospital’s system of just culture.  So much for the non-punitive policy of the hospital.

     As a result of the pharmacist being suspended, medication error report numbers in my hospital dropped dramatically.  In fact, they never recovered.  My hospital stated that they had a non-punitive policy.  My hospital claimed that they had an atmosphere of just culture.  But the action of a pharmacist being suspended for three days without pay spoke louder than any administrator’s words.

     Many hospitals have exceptional programs. They have very good systems which minimize medication errors.  These facilities also have a true just culture atmosphere which works to address medication errors.  These programs blame the medication error on the system rather than the individual worker.  They also work to correct and eliminate medication errors.

     Unfortunately, like most things in today’s society, the focus isn’t on these facilities that do the right thing.  We seldom hear about them.  Instead, we hear about the mishaps that occur with medication errors.

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