When Healthcare Providers Make Mistakes

Don't be a Nurse Puppet. photo: J.Paradisi

Don't be a Nurse Puppet. photo: J.Paradisi

   Pauline Chen writes about doctors who make mistakes in the health section of the New York Times (When Doctors Make Mistakes )http://www.nytimes.com/2009/07/09/health/09chen.html?_r=1&partner=rss&emc=rss

On the same page of today’s on-line section, is a story about an ex-surgery technician who infected at least ten people with hepatitis C, by stealing drugs from patients, injecting them into herself, then reusing the needles and syringes on patients.  http://www.nytimes.com/2009/07/10/us/10denver.html?ref=health

   There is a huge difference between making a mistake and committing a crime.  I think that point gets confused sometimes in the discussion of errors made in health care.

   When I was going through chemotherapy for cancer treatment, I couldn’t work with patients in the PICU. Instead, I was assigned to Quality Insurance for the unit. The job involved reviewing error reports, identifying events leading  to errors, and creating systems to prevent recurrence. I loved that job.  A consistent thread running through virtually every report was rarely do single events lead to mistakes. Usually a series of events occur, like a stack of dominoes falling upon each other in a line, leading to Destination Error.  Long hours, too heavy patient loads, extra shifts to cover short staffing, lack of appropriate mentoring for new nurses and doctors, and more, contribute to mistakes. There was always a surge in reports when census was high and staffing was low.

   During the first six months of my nursing career, I thought I  made a disastrous error: becoming a nurse.  Fresh out of school, I worked on a high-acuity unit  utilizing the team-leader model of care. I was a team leader for one LPN (if one was available) and one or two CNAs. If someone called in sick, I was also charge nurse, with a full patient assignment. I worked twelve hour nights and went home most mornings in tears, dreading the little notes I’d find in my staff box, notifying me of things I’d forgotten or mistakes I’d made the previous shift. It never occurred to me the assignments were unreasonable. Instead, I doubted myself, a competent young woman, managing a household and raising a family, feeling unable to do a job I worked so hard to excel at.

   I was rescued by an expert nurse who befriended me and taught me what nursing is really about. If I could wish anything for new nurses, it would be for each to have that kind of mentoring, which for some reason came my way.  I hope I gave some of that back when it was my turn to precept and mentor.

   Be careful out there.