Handling Mistakes with Patients
Posted: 12/14/2016 8:08 AM by Interim HealthCare
Have you ever made a mistake or had an error in clinical judgement that caused patient consequences?
Most people in the caring professions are compassionate and conscientious people and are horrified to discover that they have directly or indirectly caused a medical error that may have caused harm. In today’s fast paced and constantly changing workplace, it is easy to see how miscommunications, low staffing levels, and sheer information overload can contribute to someone making a mistake. Sometimes actions or omissions may cause patients serious consequences or even death.
The Institute of Medicine has studied medical errors and set up guidelines for the review of medical errors. The focus of the review is to shift away from blaming individuals to examining systems and how they can be changed to prevent errors. This has brought about procedures like the Pre-op Time Out, where everyone in the operating room triple checks the patient information and identity and confirms marks on the patient saying "operative site". Bar codes on ID bracelets are another system change that has prevented many medication errors.
If you have made an error, please do not keep it to yourself and suffer in silence. Tell your supervisor as soon as possible, so patient consequences can be minimized, and an investigation can be initiated into the root cause of the event. Thorough investigations can help determine if changes in procedures are needed to help prevent a reoccurrence of the error.
It’s not an exaggeration to say that one of the things every nurse fears the most is making a fatal error in judgement. The huge responsibility lying on a nurse’s shoulders makes it especially hard for any nurse to acknowledge that, sometimes, mistakes might happen. Wrapping your mind around the impact that such an error might have on you is not easy.
There are two main factors to consider. The first is the patient outcome and effects on patient’s health. The second factor is the degree of personal responsibility felt by you. The higher both are, the stronger the distress you feel after the error.
1. Stay Calm: The error has been made and the only thing that matters now is to make sure you handle it correctly by following established protocol.
2. Take Accountability: You can release a lot of distress by simply discussing it with your supervisor and co-workers. Allow them to guide and support you.
3. Have Some Error Disclosure: With your supervisor, decide when or if having a disclosure with your patient is appropriate based on established protocol.
4. Analyze the Error Contributing Factors: Whatever the reasons, you have to be able to look at them clearly, identify, and document what happened.
5. Come Up with an Action Plan: This allows you to bring whatever improvement you can to the situation, and to create a plan around how similar situations can be prevented in the future.
To err is human. How you handle your mistakes is what is most important. So, don’t be too harsh on yourself and try to learn as much as possible from the mistake.