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I recently had a client tell me that she was going to leave nursing. She told me this after we had been working for a number of years to respond to a nursing board investigation. Working in an understaffed facility with numerous system and process failures, she made a mistake. The mistake itself was unsettling. But it was the Kafka-esque experience that followed the mistake that was taking its toll on her.
Nurses are expected to play whack-a-mole when administering medications. The organizations set them up to make errors, then play gotcha & hammer them when they do. Despite the wealth of available information about the effects of distraction and interruption on performance, her employer did not have “no interruption zones” so nurses could commit their undivided attention to the preparation and administration of medications. It did not have safe labeling practices. It did not use a Pyxis or Omnicell system for controlled substances. Like many other organizations, it put profits above patient safety. And when the inevitable error occurred, the response was to blame the nurse rather than accepting responsibility as an organization for its own failings.
The punitive nature of her employer’s response to that medication error was then followed by the nursing board’s startlingly harsh disciplinary response. Neither her employer, nor the nursing board were willing to see the event for what it was – a good, conscientious health professional working in a dangerous system who made an unintentional human error. Both the facility and the regulatory agency charged with protecting the public found it far easier to simply see her as the bad guy, accuse her of gross negligence, and make her bear the entire weight of an adverse event.
In this last domino approach to error analysis, all the other dominos can fall with impunity, but the last domino to fall is the one responsible for the collapse. Physicians or NPs can order medications inaccurately. The pharmaceutical companies can package dangerously different medications in a look-alike, sound-alike form. Pharmacies can dispense different medications with misleading or identical labels and tiny font. Health care facilities can have inadequate procedural safeguards. None of that matters. The only thing that matters when all of these systemic failures lead to error, is that the nurse wasn’t careful enough. The nurse did not meet the standard of practice. The nurse was unable to overcome human limitations and prop up all the preceding falling dominoes. So the nurse must be punished.
The zeal to blame individuals ignores the reality that medical errors happen to the best of providers in the best of organizations. Human beings cannot attain perfection and when mistakes are made, the providers making them suffer emotional distress, anxiety, guilt, fear, shame, and a loss of confidence. They can lose the ability to recover and return to practice. Our employers and our regulatory agencies need to understand this and respond to adverse events with current safety and just culture theories in mind. Until they do, providers who are stressed or even traumatized by these experiences need the support of their colleagues.
As coworkers we need to be there for others going through an experience that could happen to any of us. We can’t let each other suffer the isolation that intensifies the depression. Nurses have a higher suicide rate than other professions. The engagement of one’s coworkers in the struggle can make all the difference. I hope my client does not leave the nursing profession. I hope Jacintha Saldanha and Kimberly Hiatt were able to receive some comfort from those with whom they had worked. And if you make a mistake - an unintentional human error - I hope your coworkers will be there for you. I hope they will provide the peer support to get you through it. And I hope you will do the same for them. Because Martin Luther King Jr. said it best when he said, “In the End, we will remember not the words of our enemies, but the silence of our friends.”
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