Mistakes are the usual bridge between inexperience and wisdom. Phyllis Theroux
Though nurses are the primary caregivers in hospitals, in India today they are still treated very shabbily. We need to overhaul our nursing curriculum, so that nurses can command the respect they deserve, and act as partners in the safe delivery of patient care.
Nurses are very busy, and the more patients they have to look after, the greater their chances of committing an error. There is a strong correlation between nurse staffing (both as regards to the number of patients each nurse has to look after, as well as the quality of her education) and patient outcomes. Because it’s so hard to find trained nurses in India, family members often have to be roped in to provide nursing care for patients.
In a busy hospital, a single patient can receive more than 20 doses of medication per day, while a nurse can administer as many as 100 medications per shift. A heavy work load and erratic work hours can sap anyone’s energy and decrease their competence. Fatigue, stress and complacency can all lead to deadly mistakes, and often this is a disaster waiting to happen, especially at night-time, or on the weekend, when there are fewer nurses on duty. This is why medication errors are so common. They occur because of:
* Illegibly written orders
* Dispensing errors
* Calculation errors
* Monitoring errors
* Administration errors
Check the “five rights” The right patient, the right drug, the right dose, the right route, and the right time! The five rights don’t just describe the nurse’s responsibility for achieving medication safety; they are also goals for which the hospital administration must accept responsibility so that it can design failsafe ways to achieve them. Some of the measures that can be taken are:
* The prescribing process is the Achilles’ heels of medication safety. For example, illegible prescriptions are a fertile breeding ground for error. Computerized physician order entry (CPOE) prevents this problem. CPOE also reduces the risk of dangerous drug interactions; the wrong dosage being prescribed; and minimizes incorrect drug choices.
* Verbal orders and those given over the phone should be verified by “reading back”. Drug names should be spelled out using the phonetic alphabet.
* Nurses should request a colleague to double-check medications when giving high-alert drugs
* All known allergies should be clearly documented. Nursing staff should be made aware of various allergic reactions , and be trained to deal with them promptly.
* Protocols should be carefully followed with high-risk drugs, such as chemotherapy drugs used for treating patients with cancer, because these can be very toxic. These include close monitoring of the patient, good training of the nursing staff and well-maintained infusion pumps.
* Out-of-date medicines must be immediately disposed.
* Handoffs and transitions occur when patients are moved from the ICU or OT to the ward, or when the shift changes and new staff come on duty. These are occasions when the risk for error is high. Handoffs should occur at designated times and without distraction. All documentation must be complete and in order; and all medications should be reconciled.
* Particular care must be taken with elderly patients, children and pregnant women, or with disabled patients or those who do not speak the same language
* In a busy ward, the workflow needs to be properly organized by the Head Nurse, in order to prevent unnecessary distractions and interruptions * Using standardized order sets and pre rinted protocols helps nurses to select correct dosing regimens and routes while eliminating ambiguous abbreviations and the risk of misreading a prescriber’s handwriting.
* Medications for use in the hospital should be provided in clearly labeled unit-dose packages.
* High-risk medications should be stored under lock and key.
* Patients should be taught the name of each medication they’re taking, how to take it, the dosage, potential adverse effects and what it’s being used to treat, so they can protect themselves from mistakes
* There are more details on how nurses can reduce medication risks
Nurses as the first line of defense against errors
Nurses are the primary caregivers at the bedside, and since they are the ones who spend the most time with the patient, they are often the first ones to notice when an error is being made. What should a nurse do when she observes the doctor making a potential mistake? While it’s easy to talk about the importance of reporting medical errors, the truth is that it is often very hard for a nurse to speak up when she sees a doctor making an error.
Does she report the mistake? And to whom? Nurses are very junior in the medical hierarchy in India, and it’s not easy for someone who is so low on the totem pole to report a mistake made by a senior doctor, in order to protect her patient from harm, even though she knows it’s the right thing to do. Nurses are understandably scared that this reporting will be considered to be an act of insubordination, and they will have to pay a steep price if they dare to open their mouth.
This is a thorny dilemma, because she has to choose between preventing harm to the patient, and her loyalty to the doctor, her colleagues, supervisors, and the hospital. There is an imbalance of power involved in the act, and although there are some cases where hospitals have rewarded whistleblowers for their efforts, the typical response of the manager or colleagues is harassment and mistreatment.
Nurses who have complained have often been forced to resign because the management makes their life miserable, in order to shut them up. They are intimidated by doctors, and the junior nurse is often uncertain about her own competence. Also, since sticking her neck out carries a risk that she can get hurt, why should she bother? After all, if everyone else is keeping quiet, why should she open her mouth?
She may also be unsure what the procedure for complaining is, and silence is often the easier option, so she may choose to turn a blind eye to the error. It’s easy for a junior nurse to justify her stance by saying – It’s not really any of my business. I should do my job, and not interfere with what the doctor does.
The right path
However, the reality is that nurses should put their patients first, and their code of ethics obliges them to be patient advocates and to take action when a patient’s safety is endangered. Enlightened doctors will appreciate the nurse’s efforts to prevent harm to their patients; and good hospital managers will make it as easy as possible for nurses to report near-misses without fearing harm.
A qualified nurse is not the “handmaiden” of the doctor. She is an important resource and must remain vigilant, ready to detect anything amiss in the care of the patient, who is put under her charge. An efficient safety culture does not recognize hierarchy and allows subordinates to speak up without the fear of retaliation. Nurses have to learn to speak up when they feel something has gone awry.