Health assessment

JustCulturePowerpointNU350.pptx

Close Calls in Nursing: What if it was you?

Just Culture Assignment NU350 | Glenda Fullbright

Did You Assess the Patient?

What happened?

Patient unable to express pain and discomfort

How long would it go unnoticed?

Nurse frustrated and overlooked small detail

How did you respond?

Feelings of disbelief, anger, empathy, and compassion

How did the family respond?

Understanding, glad it was resolved

A nurse had orders to collect labs on a patient. After multiple attempts, the nurse was unsuccessful and asked if I could try. When I arrived at the home, I noticed the patient’s arm looked wrong. The tourniquet was left on the patient’s arm. The patient had a stroke in the past and was unable to express pain or discomfort. The patient’s husband came into the room shortly after and informed me he had checked her blood pressure earlier and it was high. He laughed that it must have been high because of the tourniquet. Thankfully, the husband was forgiving and understood mistakes happen. It made me sad for the patient because she could not advocate for herself and must have been in pain for a long time. I also felt empathetic for the nurse because I know she is a good nurse, just made a mistake due to being tired from being overworked.

2

Error Probability Increases with Increasing Fatigue

“Medication administration errors (MAEs) cause preventable patient harm and cost billions of dollars from already-strained healthcare budgets. An emerging factor contributing to these errors is nurse fatigue. 82% of the studies identified fatigue to be a contributing factor in MAEs and near misses (NMs). Fatigue is associated with reduced cognitive performance and lack of attention and vigilance. It is associated with poor nursing performance and decreased patient safety. Components of shift work, such as disruption to the circadian rhythm and overtime work, were identified as contributing factors.” (Bell et al., 2023)

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

3

Implementing a Just Culture Model

A Just Culture is meant to improve outcomes fairly. What exactly does this mean? Fairness means giving each person involved a fighting chance. Instead of focusing on the error, focus on the person’s credibility. Facilities require perfection from their employees which creates unrealistic expectations. Nurses are afraid to come forward when they make a mistake for fear of reprimand like suspension of their nursing license, fines, or even jail time. The Just Culture Model focuses on looking at the person’s character and not just the mistake. It is a learning culture. The term just culture is commonly used to describe processes within organizations aiming to achieve a fair conclusion for those involved in an incident or a near miss. The key to a just culture is a focus on openness, repairing harm, and learning rather than blaming (Baarle et al., 2022).

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

4

Where do I start?

The nurse did not make this mistake on purpose. Just Culture defines three key behaviors, human error being one. Human error is an inadvertent action. How do we manage this? We recognize the mistake and figure out how we can learn from it.

What if you were in that nurse’s shoes? We forget how easily mistakes can be made especially when we are frustrated, tired, overworked, or stressed. We need to practice the golden rule: “treat others how you want to be treated.”

That nurse is normally a wonderful, attentive nurse. Before placing blame, ask the nurse if there is anything going on. Sometimes just having someone to talk to can make all the world of difference.

Practice what you preach. Just Culture means not forgetting that we are all human. Understand mistake happen but can be used as an effective learning experience.

5

First, look at the situation realistically. The patient was not harmed intentionally. The nurse made an honest, human error.

Second, consider the action. Could you have done the same thing? How would you want someone to react to a mistake you made?

Third, look at the nurse’s situation. Is that nurse tired? Have they been working a lot lately? Are they having personal issues?

Fourth, implement the just culture that targets the systems and behaviors that led to the error or outcome and makes the correct changes.

Improving Outcomes for Every Patient Every Time

Using a systems-based approach, we can identify the risk factors that could lead to an error like this one. Increased fatigue is an issue that affects patient care and the nurses’ quality of work. Understanding what is causing this fatigue and burnout is crucial to preventing further mistakes. The FMEA Model is meant to identify failure, assess the risks, and prioritize action. This process examines the individual components of a system to determine the variety of ways each component could fail and the effect of a particular failure on the stability of the entire system (El-Awady, 2023).

There are multiple risk factors that could cause an error in healthcare. This particular error was most likely caused by the nurse being tired and burnt out. How do we fix this? Use this as an example for other nurses without using any names. This will make other nurses more aware in a similar situation when doing something that is like muscle memory where we may forget or overlook a step. It will make a nurse think, “I’m glad that wasn’t me,” and work hard not to do the same thing. I also believe that sharing this experience will humanize the nurses to each other and have more compassion when dealing with a patient after a different nurse. It may help to lead a mindset of understanding the situation first instead of going straight into judgement.

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

6

Second Victim Syndrome

Second Victim Symptoms are the result of a traumatic patient care event in the healthcare setting. These events can include near misses, patient adverse events, deaths, or provider mistakes but really encompass any event that leads to significant mental stress on the part of the provider (otherwise known as the "second victim") (Sachs, 2023). This phrase was coined to describe the first victim as the patient and the second victim as the healthcare provider. Feeling this way can happen at any timeline after an adverse event and the causing event can be any type of error made where the patient has a poor or potentially poor outcome. These second victim symptoms can include troubling memories, anxiety/concern, anger towards themselves, regret/remorse, distress, fear of future errors, embarrassment, guilt, and sleeping difficulties.

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

7

War With My Mind

We will all feel guilty or responsible at one point in our nursing careers. Being the second victim means blaming yourself and allowing that guilt to take control. After an error occurs, it is difficult not to dwell on the event and try to figure out exactly what went wrong. Being at constant battle with your mind can cause anxiety, stress, or depression. This worry can lead to another error and more guilt. To battle this second victim syndrome, nurses must be able to admit mistakes without judgement. If more nurses are willing to admit mistakes, it will be a more natural discussion. We all mess up from time to time, but pretending like we never do is the problem.

Be Right Back, I’m Taking Control of My Life

Treatment is based on the individual person and support provided. Organizational strategies include programs to support second victim syndrome. Such programs provide rapid response teams available 24/7, peer support groups, and non-punitive communication of adverse events within the healthcare team (Kappes et al., 2021). The main issue with second victim syndrome is the lack of adequate support when a mistake is made. Implementing change and providing appropriate resources can change the narrative for nurses.

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

9

Remember What You Have Learned

Think of a time where you made an error or when you were the first one to catch an error. What was your first thought? Do you think that thought would be different now? The only way to implement true change is to practice that change in our everyday lives. To create a safe environment where nurses can openly report errors and behaviors requires systems to be in place to decrease stigmas around nursing errors. We should learn to stop requiring perfection of nurses and ourselves.

We are only human.

10

References

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

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.MsftOfcThm_Accent1_Fill_v2 { fill:#00C6BB; } .MsftOfcThm_Accent1_Stroke_v2 { stroke:#00C6BB; }

power-point.docx

Identify an error or near miss (close call) that you have encountered in the clinical practice setting. Consider the impact of the error on patient outcomes. For example, was the error disclosed to the patient and family, how did the administration respond to the error initially and were strategies implemented to prevent the error or near miss from occurring again? Please do not identify the healthcare agency where the error occurred, or the individuals involved (HIPAA). Elaborate on how the error made you feel. What thoughts and fears did it provoke in you?

As you reflect on this event, use the concepts related to a “Just Culture” (PowerPoint presentation from David Marx) and the proactive approach of “ Failure Mode Effects Analysis” (resource provided by Institute on Healthcare Improvement) and share how as a nurse leader /manager that you would address this safety concern in the healthcare organization. Discuss in detail the idea of a “second victim" and how as a manager you could provide support to your staff and promote a “just culture”. Use scholarly in-text citations to support your decisions.

Develop a narrated/voice-over/recorded PowerPoint presentation discussing the error/near miss and incorporate the ideas from David Marx's ppt and the Failure Mode Effects Analysis on resolving the issue, second victim, and a manager's role in handling this safety concern. Upload your narrated PowerPoint to the link provided AND in the discussion forum area on the next page as your initial post and then reply to a minimum of four of your peers . (Follow the grading rubric and do not forget to include a reference slide at the end of your PowerPoint.)

I will record my voice to PowerPoint after you finish it.

See grading rubric.

NU350RubricAJUSTCULTUREpptanddiscussion05-20231.docx

Module 5 Grading Rubric

A Just Culture PowerPoint and Discussion Forum

Identification of an error or near miss in the healthcare setting revealing the impact (real or potential) on patient outcomes and sharing of personal insights gained from the medical error.	Points possible 5	Minimum of 2 slides excluding Title slide. *You may include notes at the bottom of the slide to prevent overcrowding on the slide.
Incorporation of concepts (a systematic approach, instead of assigning blame) from David Marx (5 points) and the Institute of Healthcare Improvement FMEA (5 points) to address the identified medical error. Citation of resources required in the notes section on the PPT.	Points possible 10	Minimum of 3 slides. Includes thorough application of concepts.
Reflects critical thinking related to the idea of “second victim” and implementing change in practice. Identify a work policy that is in place for this occurrence and include a conclusion slide.	Points possible 10	Minimum of 3 slides excluding Conclusion and Reference slide.
Responds to a minimum of four peers. Follows directions regarding posts.	Points possible 20	*Please note that for this discussion forum that you MUST interact frequently with your peer group (At minimum, two posts to peers regarding feedback about their presentation and two responses to peers that have evaluated your presentation). There should be four or more posts for grading. Note: Responses to peers must be scholarly and more than just one sentence and "thank you".
Follows APA guidelines for grammar and clarity in powerpoint and discussion reponses. Includes title and reference slide. References should also be on the notes section below the powerpoint.	Points possible 5	Total of 10 slides minimum.

**Possible deductions/Failure of this assignment can occur if: Voice over/recording does not work; No communication with peers; Presentation is less than 3 minutes or greater than 6 min.

JustCulturePowerpointNU350.pptx

Close Calls in Nursing: What if it was you?

Just Culture Assignment NU350 | Glenda Fullbright

Did You Assess the Patient?

What happened?

Patient unable to express pain and discomfort

How long would it go unnoticed?

Nurse frustrated and overlooked small detail

How did you respond?

Feelings of disbelief, anger, empathy, and compassion

How did the family respond?

Understanding, glad it was resolved

A nurse had orders to collect labs on a patient. After multiple attempts, the nurse was unsuccessful and asked if I could try. When I arrived at the home, I noticed the patient’s arm looked wrong. The tourniquet was left on the patient’s arm. The patient had a stroke in the past and was unable to express pain or discomfort. The patient’s husband came into the room shortly after and informed me he had checked her blood pressure earlier and it was high. He laughed that it must have been high because of the tourniquet. Thankfully, the husband was forgiving and understood mistakes happen. It made me sad for the patient because she could not advocate for herself and must have been in pain for a long time. I also felt empathetic for the nurse because I know she is a good nurse, just made a mistake due to being tired from being overworked.

2

Error Probability Increases with Increasing Fatigue

“Medication administration errors (MAEs) cause preventable patient harm and cost billions of dollars from already-strained healthcare budgets. An emerging factor contributing to these errors is nurse fatigue. 82% of the studies identified fatigue to be a contributing factor in MAEs and near misses (NMs). Fatigue is associated with reduced cognitive performance and lack of attention and vigilance. It is associated with poor nursing performance and decreased patient safety. Components of shift work, such as disruption to the circadian rhythm and overtime work, were identified as contributing factors.” (Bell et al., 2023)

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

3

Implementing a Just Culture Model

A Just Culture is meant to improve outcomes fairly. What exactly does this mean? Fairness means giving each person involved a fighting chance. Instead of focusing on the error, focus on the person’s credibility. Facilities require perfection from their employees which creates unrealistic expectations. Nurses are afraid to come forward when they make a mistake for fear of reprimand like suspension of their nursing license, fines, or even jail time. The Just Culture Model focuses on looking at the person’s character and not just the mistake. It is a learning culture. The term just culture is commonly used to describe processes within organizations aiming to achieve a fair conclusion for those involved in an incident or a near miss. The key to a just culture is a focus on openness, repairing harm, and learning rather than blaming (Baarle et al., 2022).

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

4

Where do I start?

The nurse did not make this mistake on purpose. Just Culture defines three key behaviors, human error being one. Human error is an inadvertent action. How do we manage this? We recognize the mistake and figure out how we can learn from it.

What if you were in that nurse’s shoes? We forget how easily mistakes can be made especially when we are frustrated, tired, overworked, or stressed. We need to practice the golden rule: “treat others how you want to be treated.”

That nurse is normally a wonderful, attentive nurse. Before placing blame, ask the nurse if there is anything going on. Sometimes just having someone to talk to can make all the world of difference.

Practice what you preach. Just Culture means not forgetting that we are all human. Understand mistake happen but can be used as an effective learning experience.

5

First, look at the situation realistically. The patient was not harmed intentionally. The nurse made an honest, human error.

Second, consider the action. Could you have done the same thing? How would you want someone to react to a mistake you made?

Third, look at the nurse’s situation. Is that nurse tired? Have they been working a lot lately? Are they having personal issues?

Fourth, implement the just culture that targets the systems and behaviors that led to the error or outcome and makes the correct changes.

Improving Outcomes for Every Patient Every Time

Using a systems-based approach, we can identify the risk factors that could lead to an error like this one. Increased fatigue is an issue that affects patient care and the nurses’ quality of work. Understanding what is causing this fatigue and burnout is crucial to preventing further mistakes. The FMEA Model is meant to identify failure, assess the risks, and prioritize action. This process examines the individual components of a system to determine the variety of ways each component could fail and the effect of a particular failure on the stability of the entire system (El-Awady, 2023).

There are multiple risk factors that could cause an error in healthcare. This particular error was most likely caused by the nurse being tired and burnt out. How do we fix this? Use this as an example for other nurses without using any names. This will make other nurses more aware in a similar situation when doing something that is like muscle memory where we may forget or overlook a step. It will make a nurse think, “I’m glad that wasn’t me,” and work hard not to do the same thing. I also believe that sharing this experience will humanize the nurses to each other and have more compassion when dealing with a patient after a different nurse. It may help to lead a mindset of understanding the situation first instead of going straight into judgement.

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

6

Second Victim Syndrome

Second Victim Symptoms are the result of a traumatic patient care event in the healthcare setting. These events can include near misses, patient adverse events, deaths, or provider mistakes but really encompass any event that leads to significant mental stress on the part of the provider (otherwise known as the "second victim") (Sachs, 2023). This phrase was coined to describe the first victim as the patient and the second victim as the healthcare provider. Feeling this way can happen at any timeline after an adverse event and the causing event can be any type of error made where the patient has a poor or potentially poor outcome. These second victim symptoms can include troubling memories, anxiety/concern, anger towards themselves, regret/remorse, distress, fear of future errors, embarrassment, guilt, and sleeping difficulties.

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

7

War With My Mind

We will all feel guilty or responsible at one point in our nursing careers. Being the second victim means blaming yourself and allowing that guilt to take control. After an error occurs, it is difficult not to dwell on the event and try to figure out exactly what went wrong. Being at constant battle with your mind can cause anxiety, stress, or depression. This worry can lead to another error and more guilt. To battle this second victim syndrome, nurses must be able to admit mistakes without judgement. If more nurses are willing to admit mistakes, it will be a more natural discussion. We all mess up from time to time, but pretending like we never do is the problem.

Be Right Back, I’m Taking Control of My Life

Treatment is based on the individual person and support provided. Organizational strategies include programs to support second victim syndrome. Such programs provide rapid response teams available 24/7, peer support groups, and non-punitive communication of adverse events within the healthcare team (Kappes et al., 2021). The main issue with second victim syndrome is the lack of adequate support when a mistake is made. Implementing change and providing appropriate resources can change the narrative for nurses.

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

9

Remember What You Have Learned

Think of a time where you made an error or when you were the first one to catch an error. What was your first thought? Do you think that thought would be different now? The only way to implement true change is to practice that change in our everyday lives. To create a safe environment where nurses can openly report errors and behaviors requires systems to be in place to decrease stigmas around nursing errors. We should learn to stop requiring perfection of nurses and ourselves.

We are only human.

10

References

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

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media3.m4a

media4.m4a

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.MsftOfcThm_Accent1_Fill_v2 { fill:#00C6BB; } .MsftOfcThm_Accent1_Stroke_v2 { stroke:#00C6BB; }

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.MsftOfcThm_Accent1_Fill_v2 { fill:#00C6BB; } .MsftOfcThm_Accent1_Stroke_v2 { stroke:#00C6BB; }

power-point.docx

Identify an error or near miss (close call) that you have encountered in the clinical practice setting. Consider the impact of the error on patient outcomes. For example, was the error disclosed to the patient and family, how did the administration respond to the error initially and were strategies implemented to prevent the error or near miss from occurring again? Please do not identify the healthcare agency where the error occurred, or the individuals involved (HIPAA). Elaborate on how the error made you feel. What thoughts and fears did it provoke in you?

As you reflect on this event, use the concepts related to a “Just Culture” (PowerPoint presentation from David Marx) and the proactive approach of “ Failure Mode Effects Analysis” (resource provided by Institute on Healthcare Improvement) and share how as a nurse leader /manager that you would address this safety concern in the healthcare organization. Discuss in detail the idea of a “second victim" and how as a manager you could provide support to your staff and promote a “just culture”. Use scholarly in-text citations to support your decisions.

Develop a narrated/voice-over/recorded PowerPoint presentation discussing the error/near miss and incorporate the ideas from David Marx's ppt and the Failure Mode Effects Analysis on resolving the issue, second victim, and a manager's role in handling this safety concern. Upload your narrated PowerPoint to the link provided AND in the discussion forum area on the next page as your initial post and then reply to a minimum of four of your peers . (Follow the grading rubric and do not forget to include a reference slide at the end of your PowerPoint.)

I will record my voice to PowerPoint after you finish it.

See grading rubric.

NU350RubricAJUSTCULTUREpptanddiscussion05-20231.docx

Module 5 Grading Rubric

A Just Culture PowerPoint and Discussion Forum

Identification of an error or near miss in the healthcare setting revealing the impact (real or potential) on patient outcomes and sharing of personal insights gained from the medical error.	Points possible 5	Minimum of 2 slides excluding Title slide. *You may include notes at the bottom of the slide to prevent overcrowding on the slide.
Incorporation of concepts (a systematic approach, instead of assigning blame) from David Marx (5 points) and the Institute of Healthcare Improvement FMEA (5 points) to address the identified medical error. Citation of resources required in the notes section on the PPT.	Points possible 10	Minimum of 3 slides. Includes thorough application of concepts.
Reflects critical thinking related to the idea of “second victim” and implementing change in practice. Identify a work policy that is in place for this occurrence and include a conclusion slide.	Points possible 10	Minimum of 3 slides excluding Conclusion and Reference slide.
Responds to a minimum of four peers. Follows directions regarding posts.	Points possible 20	*Please note that for this discussion forum that you MUST interact frequently with your peer group (At minimum, two posts to peers regarding feedback about their presentation and two responses to peers that have evaluated your presentation). There should be four or more posts for grading. Note: Responses to peers must be scholarly and more than just one sentence and "thank you".
Follows APA guidelines for grammar and clarity in powerpoint and discussion reponses. Includes title and reference slide. References should also be on the notes section below the powerpoint.	Points possible 5	Total of 10 slides minimum.

**Possible deductions/Failure of this assignment can occur if: Voice over/recording does not work; No communication with peers; Presentation is less than 3 minutes or greater than 6 min.

JustCulturePowerpointNU350.pptx

Close Calls in Nursing: What if it was you?

Just Culture Assignment NU350 | Glenda Fullbright

Did You Assess the Patient?

What happened?

Patient unable to express pain and discomfort

How long would it go unnoticed?

Nurse frustrated and overlooked small detail

How did you respond?

Feelings of disbelief, anger, empathy, and compassion

How did the family respond?

Understanding, glad it was resolved

A nurse had orders to collect labs on a patient. After multiple attempts, the nurse was unsuccessful and asked if I could try. When I arrived at the home, I noticed the patient’s arm looked wrong. The tourniquet was left on the patient’s arm. The patient had a stroke in the past and was unable to express pain or discomfort. The patient’s husband came into the room shortly after and informed me he had checked her blood pressure earlier and it was high. He laughed that it must have been high because of the tourniquet. Thankfully, the husband was forgiving and understood mistakes happen. It made me sad for the patient because she could not advocate for herself and must have been in pain for a long time. I also felt empathetic for the nurse because I know she is a good nurse, just made a mistake due to being tired from being overworked.

2

Error Probability Increases with Increasing Fatigue

“Medication administration errors (MAEs) cause preventable patient harm and cost billions of dollars from already-strained healthcare budgets. An emerging factor contributing to these errors is nurse fatigue. 82% of the studies identified fatigue to be a contributing factor in MAEs and near misses (NMs). Fatigue is associated with reduced cognitive performance and lack of attention and vigilance. It is associated with poor nursing performance and decreased patient safety. Components of shift work, such as disruption to the circadian rhythm and overtime work, were identified as contributing factors.” (Bell et al., 2023)

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

3

Implementing a Just Culture Model

A Just Culture is meant to improve outcomes fairly. What exactly does this mean? Fairness means giving each person involved a fighting chance. Instead of focusing on the error, focus on the person’s credibility. Facilities require perfection from their employees which creates unrealistic expectations. Nurses are afraid to come forward when they make a mistake for fear of reprimand like suspension of their nursing license, fines, or even jail time. The Just Culture Model focuses on looking at the person’s character and not just the mistake. It is a learning culture. The term just culture is commonly used to describe processes within organizations aiming to achieve a fair conclusion for those involved in an incident or a near miss. The key to a just culture is a focus on openness, repairing harm, and learning rather than blaming (Baarle et al., 2022).

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

4

Where do I start?

The nurse did not make this mistake on purpose. Just Culture defines three key behaviors, human error being one. Human error is an inadvertent action. How do we manage this? We recognize the mistake and figure out how we can learn from it.

What if you were in that nurse’s shoes? We forget how easily mistakes can be made especially when we are frustrated, tired, overworked, or stressed. We need to practice the golden rule: “treat others how you want to be treated.”

That nurse is normally a wonderful, attentive nurse. Before placing blame, ask the nurse if there is anything going on. Sometimes just having someone to talk to can make all the world of difference.

Practice what you preach. Just Culture means not forgetting that we are all human. Understand mistake happen but can be used as an effective learning experience.

5

First, look at the situation realistically. The patient was not harmed intentionally. The nurse made an honest, human error.

Second, consider the action. Could you have done the same thing? How would you want someone to react to a mistake you made?

Third, look at the nurse’s situation. Is that nurse tired? Have they been working a lot lately? Are they having personal issues?

Fourth, implement the just culture that targets the systems and behaviors that led to the error or outcome and makes the correct changes.

Improving Outcomes for Every Patient Every Time

Using a systems-based approach, we can identify the risk factors that could lead to an error like this one. Increased fatigue is an issue that affects patient care and the nurses’ quality of work. Understanding what is causing this fatigue and burnout is crucial to preventing further mistakes. The FMEA Model is meant to identify failure, assess the risks, and prioritize action. This process examines the individual components of a system to determine the variety of ways each component could fail and the effect of a particular failure on the stability of the entire system (El-Awady, 2023).

There are multiple risk factors that could cause an error in healthcare. This particular error was most likely caused by the nurse being tired and burnt out. How do we fix this? Use this as an example for other nurses without using any names. This will make other nurses more aware in a similar situation when doing something that is like muscle memory where we may forget or overlook a step. It will make a nurse think, “I’m glad that wasn’t me,” and work hard not to do the same thing. I also believe that sharing this experience will humanize the nurses to each other and have more compassion when dealing with a patient after a different nurse. It may help to lead a mindset of understanding the situation first instead of going straight into judgement.

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

6

Second Victim Syndrome

Second Victim Symptoms are the result of a traumatic patient care event in the healthcare setting. These events can include near misses, patient adverse events, deaths, or provider mistakes but really encompass any event that leads to significant mental stress on the part of the provider (otherwise known as the "second victim") (Sachs, 2023). This phrase was coined to describe the first victim as the patient and the second victim as the healthcare provider. Feeling this way can happen at any timeline after an adverse event and the causing event can be any type of error made where the patient has a poor or potentially poor outcome. These second victim symptoms can include troubling memories, anxiety/concern, anger towards themselves, regret/remorse, distress, fear of future errors, embarrassment, guilt, and sleeping difficulties.

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

7

War With My Mind

We will all feel guilty or responsible at one point in our nursing careers. Being the second victim means blaming yourself and allowing that guilt to take control. After an error occurs, it is difficult not to dwell on the event and try to figure out exactly what went wrong. Being at constant battle with your mind can cause anxiety, stress, or depression. This worry can lead to another error and more guilt. To battle this second victim syndrome, nurses must be able to admit mistakes without judgement. If more nurses are willing to admit mistakes, it will be a more natural discussion. We all mess up from time to time, but pretending like we never do is the problem.

Be Right Back, I’m Taking Control of My Life

Treatment is based on the individual person and support provided. Organizational strategies include programs to support second victim syndrome. Such programs provide rapid response teams available 24/7, peer support groups, and non-punitive communication of adverse events within the healthcare team (Kappes et al., 2021). The main issue with second victim syndrome is the lack of adequate support when a mistake is made. Implementing change and providing appropriate resources can change the narrative for nurses.

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

9

Remember What You Have Learned

Think of a time where you made an error or when you were the first one to catch an error. What was your first thought? Do you think that thought would be different now? The only way to implement true change is to practice that change in our everyday lives. To create a safe environment where nurses can openly report errors and behaviors requires systems to be in place to decrease stigmas around nursing errors. We should learn to stop requiring perfection of nurses and ourselves.

We are only human.

10

References

Sachs, C. J. (2023, June 20). Second Victim Syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK572094/

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18). https://doi.org/10.1111/jocn.16620

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a just culture in healthcare organizations: Experiences in practice - BMC Health Services Research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-z

El-Awady, S. M. M. (2023, February 23). Overview of failure mode and effects analysis (FMEA): A patient safety tool. Global journal on quality and safety in healthcare. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10229026/

Kappes, M., Romera-Garcia, M., & Delgado-Hito, P. (2021b, June 12). Coping strategies in health care providers as second victims: A systematic review. International nursing review. https://pubmed.ncbi.nlm.nih.gov/34118061/

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