To Err is Human -- Even for Medical Workers
by John Rossheim
In a community hospital, a surgical technologist disinfects the wrong leg of a patient in the operating room and sets the stage for a wrong-side knee replacement. In a medical center, a nurse confuses two look-alike vials of toxic pharmaceuticals and contributes to a patient's injury by administering the wrong drug.
If you read the newspaper or spend time in hospital waiting rooms, you've heard stories like these. If you're a nurse or allied healthcare worker, you may have played a part in such painful episodes.
Medical errors are common, even epidemic. Since physicians generally supervise the work of nurses and allied health workers, they are most often associated with the storm of professional and personal consequences that medical errors can spawn. But frontline health workers often find that their careers and psyches are deeply affected by involvement in these often-irreversible calamities.
How Nurses and Allied Workers Get Involved
Nurses, for one, are often involved in high-risk medicine, especially surgery. Scrub nurses place instruments in the hands of surgeons; circulator nurses keep an eye on the whole patient and entire operating room while the surgeon concentrates on the incision site.
“The role of the RN in the operating room is patient safety,” says Betty Schultz, president of the Association of periOperative Registered Nurses. “That is our whole goal.”
Similarly, medical technologists, pharmacists, and other allied workers have much to do with the fate of patients.
Blaming Individuals vs. Systems
Many healthcare administrators are quick to blame nurses and allied workers for errors, say their advocates. Despite this practice of scapegoating individual health workers, "'nursing errors' are overwhelming[ly] attributable to inadequate staffing and systems,” the Nurses Association said in a statement.
“In the bad old days -- and in some organizations it still is the bad old days -- the person closest to the incident would be identified as having failed,” says Dr. Albert Wu, an associate professor at the Johns Hopkins School of Public Health. “This is at best disingenuous, because the root cause generally has not been identified.”
What happens when a nurse or allied healthcare worker is involved in a serious medical error? “The potential scenarios are all over the board,” says Dr. Kenneth Kizer, president of the National Quality Forum. “It could range from the hospital conducting a root-cause analysis and investigation to getting fired.”
In an error's aftermath, “usually you're expected to get some education and training, but that does recognize the underlying systems issues,” Dr. Kizer explains. “Sometimes hospitals get rid of a very valuable person, and they haven't fixed the problem.” Fixing the problem might mean redesigning those look-alike vials of dissimilar medications, for example.
The Second Victim
Healthcare workers have been described as “the second victim” of medical errors, after injured patients and their families. Guilt, shame, and self-doubt frequently accompany involvement in a medical mistake.
“The emotional impact of a serious error is very severe,” says Zane Robinson Wolf, dean of the nursing school at La Salle University and author of Medication Errors: The Nursing Experience. “With a death or permanent injury, some people stop being a nurse or pharmacist.”
It often helps health workers to confess, explain, and apologize to injured patients and their families. But litigation-wary medical chiefs, risk managers, and hospital lawyers often bar involved professionals from contact with victims.
Healthcare workers are sometimes offered psychological support by their employers. But for many, outside support, free of institutional conflicts, is more promising. Nurses and allied workers can turn to groups such as their labour unions or professional associations, or to colleagues at other institutions.
Contributing to the Solution
Involved health workers often would like to take positive action to remedy systems that have allowed errors to reach patients. But hospitals can be ambivalent about input from healthcare staff and may not want to even hear about errors that don't require a report to the outside world.
“Nurses and allied health workers are frequently frustrated,” says Wu. In case of an error, “either there's a punitive system in place and there's substantial risk in reporting, or there's no system.”
But there is hope in some efforts to improve both the reporting of errors and the safety of delivery systems. For example, a computerized physician order-entry system for pharmaceuticals can reduce serious medications errors by 55 percent, according to a 1998 study published in the Journal of the American Medical Association. In a 2003 report, the Institute of Medicine called for improvements in nurses' working conditions designed to increase patient safety.