Thursday, 6 June 2013

Drug errors need systems failure analysis not punishment

People regularly get in touch with who are in a state of shock having made a drug error and been suspended.   A knee jerk reaction by their manager?  Don’t they have any confidence in their staff?  Do they even know them?

I’m not writing here about someone who has made several errors and now needs an assessment to find out if they are safe to practice.   How did they qualify in the first place if they are unsafe?  Why weren’t they found out before now?  Systems failure and the whole problem of ‘failing’ students on their placements – having the support to do it and then to help the failing student, rather than abandoning them, seems to be the main issue here.  

If they haven’t made repeated errors, the next question should be - is something going very wrong for them in their personal lives, making concentration at work very difficult?  

Back to the usually safe practitioner – and their incompetent manager.  The manager now has to justify their draconian action so a witch hunt begins.  There’s no chance of them following the guidelines for investigations to be transparent and fair, to find out what has actually happened.  

The increasingly pressured climate of staff shortages and higher numbers of frail patients with multiple health problems means staff are at greater risk of making errors. 
What difference would a duty of candour make?  It is planned for organisations post Mid Staffs, but what of staff on the ground?  Would it help to stop suspensions for mistakes and see managers deal correctly with errors? 

Kate Wynn, our Scottish spokesperson at feels passionate about this subject and has given me permission to quote her thought provoking observations. 

    "Drug errors, as with errors in everything else, happen all the time.  If they are truly ERRORS then no-one should ever be suspended for one - even if it kills the patient, which on occasion it might do (hopefully very rarely).  We are human beings therefore we will always make mistakes.  We need nurses to be human beings - robots cannot nurse.

I believe all nurses who practise for any length of time make drug errors at one time or another and usually, or perhaps always, if they practise long enough they will make more than one.  I've made more than one (that I know of that is - I may have made one or more that I don't know about) and I believe I'm no worse in that respect than any other nurse. 

When I made my first drug error I was in bits and wracked with guilt.  I had a manager at the time who understood that it was actually a normal event and she helped me to come to terms with what I'd done by her empathic understanding.  Her attitude, quite rightly, was that my own conscience would punish me more than was justified therefore all I needed from her was compassion.  When I made my second drug error I did initially think that I was a terrible person and that no-one else had ever done such a thing.  It took me a considerable amount of time to realise that I was not failing in some way, I was only honest for reporting it.

I did not know all of this until I had nursed for more than 20 years.  Then I was the Senior Nurse of a small hospital at a time when there was a lot of talk about 'learning from the airline industry' and 'getting rid of the blame culture'.  Over a period of years and with a lot of hard work, I eventually fostered a working environment where nurses were not afraid to come forward if they realised they had made a drug error.  I'm confident that eventually all the drug errors that the nurses knew they had made were then reported.  Reporting then happened promptly so that a doctor could be consulted and any necessary action taken.  The patients were informed of the errors, as were their relatives etc.  No-one was disciplined for a genuine error.  No patients or families complained about a drug error - they thanked us for our openness.  We tried to identify where the system was wrong and to right such wrongs but errors did continue to happen, because we were all human and we were required to undertake a potentially dangerous activity. 

Were there any other outcomes?  Yes, eventually there was one - talk of a 'no-blame culture' disappeared and I was criticised personally because I had the highest number of drug errors in the wider Health Board area within my unit!!   (Of course I'm sure I didn't - the unit I managed just had the highest number of REPORTED errors.)  What's for certain is that nurses in that hospital (where I no longer work) will no more be so quick to report it if they know they have made a mistake, and that means that a patient is more likely to die or to be seriously harmed."

Great words of wisdom there from Kate and the evidence, though anecdotal, that being allowed to report without repercussions is actually much safer than a culture of punishment and blame.

Will anything change?  Sadly it seems not and we are destined to continue to open emails from honest and hardworking, over stretched staff, in shock because of the action taken against them.  Please competent managers, sort out your incompetent colleagues to get this terrible injustice stopped.  But be warned, if this is the general culture of your organisation, then you may find yourself in trouble too.



1 comment:

  1. There are an awful lot of nurses sitting in the NMC hearings lists for drug errors of no significance at all. Managers are clearly using the "errors" as an excuse to either punish people they dislike and/or as a way of getting rid of the nurse. By the lists of errors reported, some Managers clearly sit and collect these declared errors and when they have a healthy pile of them, dating back a decade or more then the Manager reports the Nurse to the NMC. Or they have been known to report a nurse for one single omitted ferrous sulphate 5mg - which the NMC because they have no common sense have made this into a hearing issue. Which ever the route, it creates a nightmare for the nurse. It make you wonder if it is a good thing to come clean about it or not...there is no such thing as a blame free NHS!

    Now I remember my last drug error. I was working night duty in an A&E on a Saturday night and we were frantic( as usual). My poor patient was an old man with bony mets and he was in great pain. So the SHO wrote him up for Oromorph, and a small dose too. 5mg. I got a colleague to come and check the oromorph with me, and we gave the patient the morphine, with pretty well no pain relief at all, because it was a tiny dose. I never returned to him to reassess his pain - I just couldn't I was too busy - and I transferred him to the ward in pain too,(I knew that to my shame).

    Unbeknown to me, instead of picking up the 5mg/5ml bottle of oromorph, I had picked up the 10mg in 5 ml, instead or something like that. So I( and my co-checker) had made a drug error and given the patient twice the prescribed
    amount. When this was discovered in the morning, there was all hell to pay and I was threatened with never being allowed to work in the hospital again,(I was permanent agency there - while I was at University trying to change my career to something other than Nursing).

    The Management of the Department was not in the least interested in the fact the patient had not had enough pain relief even though he had got more than his prescribed dose,( privately I consoled my self with this fact that at least he had got 2 doses from me, even if they weren't enough). They were not in the least interested that I thought the patients comfort mattered at least as much as this drug error. The patient and the quality of care he received was completely irrelevant. All that mattered was that the drug numbers were correct and because of me and my co checker, they weren't. Even though because we were measuring ml in a bottle it was all hypothetical, anyway). The co-checker was furious with me for "making him make the error". Funny how some can't take responsibility for their own actions. And he never spoke to me again.

    In the end the dust settled and they admitted that they knew I had not done it on purpose and they knew I would be careful in future... but the patient still didn't enter their reckoning, to my regret.

    And the logic of Nurses still is beyond me, after 30 years. why don't they chew on the big stuff and spit out the small issues? And not try and stab each other in the back... where is the benefit of that?