Let’s talk about some numbers first:
20 years ago (1999) The Institute of Medicine put out a report called “To Err is Human”. It estimated 98,000 people a year die from preventable medical errors.
This costs an estimated $17-29 billion a year.
Where do you think that number is now? More or less? A recent study by Johns Hopkins estimated over 250,000 people a year die because of medical errors. Some other reports estimate at even a higher rate. (It is challenging to get a more accurate number because the CDC relies on death certificates for statistics).
This makes medical errors the third leading cause of death right under heart disease and cancer.
So who is to blame for this? Doctors? Nurses? The hospitals?According to the study, it is multiple reasons and ultimately a systems failure. Inadequately skilled staff, an error in judgment or care, a system defect or a preventable adverse effect.
Health care workers are dedicated, honest, and caring people. But humans make mistakes. You can be the most caring person in the world and still make a medical error. So what can you do to prevent this?
Error Prevention Tools>>> Some hospitals have implemented similar programs to help prevent as many errors as humanly possible. Let’s go over some of them and what they really mean:
We use the acronym S.A.F.E. S is for Support the Team. A is Ask Questions. F is Focus on the Task, and E. is Effective Communication.
As a nurse, it is imperative you feel like where you work has a culture of safety. I have been on opposite ends of the spectrum and for many reasons I don’t have to list, I would never stay at a hospital that does not have safety as a top priority. It is more than just your license at stake, it is people’s lives.
Support the Team
Peer checking/ peer coaching is the first part of this. Experienced nurses, you have those days where you look to see who you’re working with and you feel a sense of relief to see it’s someone you can pair up with? A buddy to bounce things off of and ask advice for certain situations? Any nurse who’s worth their weight in gold will have a peer to help check them and be an extra set of eyes/ears/thinking. Peer coaching is when you see someone about to or just did something that was unsafe and you quickly and in real time coach them of this. It can feel uncomfortable at first but what is more uncomfortable? Having to explain to a family member a mistake was made? So speak up with your peers, do not be afraid to coach them.
Debriefing is the second part of this. Many of us have been in situations where things happened so fast, a code was called, a patient was fine one minute and next, they aren’t. You are precepting a new nurse graduate and you’ve had a very crazy shift. What do we do after all the dust has settled? Debrief. Take 5 minutes to talk about what happened, allow feelings about the incident to come out, talk about what opportunities there were to improve and what was done well. Having these crucial conversations allows for others to learn and maybe prevent a mistake or improve a process in the future. Support your teammates and let them know you are there to talk if they need to.
What do you do when things are moving too fast or something doesn’t seem right when a doctor gives you an order you don’t think is safe? You ARCC it up! Ask the question (make sure you understand), request a change (safety), voice a concern (raise a safety issue), and go up your chain of command if needed. If patient safety is your top priority, you will not be in the wrong. Any facility which promotes these steps is fostering a culture of safety. I definitely would prefer to work in a place where this is encouraged vs where I would be afraid to speak up if something didn’t seem right.
Validate and verify: Use these terms if you need to. A doctor gives you orders you don’t quite understand? Validate the order. A manager asks you to do something that doesn’t seem safe? Verify what they are asking. By using these tools and words you are red-flagging a situation in the minds of others. It might be uncomfortable at first, but you will also find you have a lot of good catches this way, whether it was on their end or a misunderstanding on yours. All it takes is 5 seconds.
Focus on the Task- this is my favorite one, I use this term a lot on my kids!
Story of my life. When I am preparing medications or drawing up insulin and someone comes up or calls etc. Nurses need to be able to work in No Distraction Zones. You might be laughing at the thought of this but they do exist! Unless a patient is unstable or there is a true emergency then it can wait 1 minute. As impatient others are to get your attention you need to focus on what you are doing especially during certain instances. It is okay to let someone know they can wait. This will also be uncomfortable at first but you will get better with it as you practice it more often.
In the event you get interrupted while doing an important task there is another tool that is very helpful- S.T.A.R. Stop, Think, Act, Review. Stop what you are doing until the interruption has ended, think about where you were in the steps, act to complete the task, and review that you did not miss anything. This is particularly useful when I am in a patient’s room and the phone rings. If I am expecting an important call from a doctor etc I will use this tool so that I can safely answer the phone. Otherwise, if I am in the middle of an important task I will let the phone ring until it is completed and call them back once I have finished. It is our nature to want to do everything at once however there are certain tasks/ situations where our patients need our full attention and focus or safety is compromised.
Effective Communication- Some of these tools you may already be using, there is a reason!
SBAR- Every nurse will recognize this tool, it is a simple and useful format for passing information and interestingly enough was created by the military (Hoo rah)
Alpha-numeric language (also from the military). “That’s 50, Five-zero milligrams”. This is very helpful especially with telephone communication.
Clarifying questions- I use this term a lot because it helps me to get the person’s attention with whom I need to clarify something. We need to have each others’ attention, especially when dealing with patients’ lives.
Read and Repeat back- every single time I get an order. Write it down whenever possible. Read and repeat back. Do not skip this step especially when in a rush because that is when mistakes are made.
Effective hand off- Make sure you are giving precise, accurate information, especially during a patient hand off. Check all lines and pumps and make sure the patient is good before handing off to another nurse. Many close calls, good catches will be found during a safe and effective hand off.
When you read and hear about these tools especially if they are pushed a lot at your job you may at first think this is silly, or unnecessary but honestly these are the tools that will help protect you and your patients from system failures. There will be mistakes in the system, no hospital is 100% safe. Nurses are ultimately the final checkpoint before the patient so we are held sometimes to the highest standards regardless if the error is our own. Make sure you are practicing with safety at the front of your mind and if you are working in an unsafe environment my recommendation is to leave that atmosphere! It is not easy, but it can be done. Even the safest nurses can be put into an unsafe situation and this can create a recipe for disaster.