Imagine yourself in a hospital, visiting someone dear to you. You have certain expectations about the hospital’s ambiance, the professionalism of the staff, and the quality of care your loved one is receiving. However, the truth is that no hospital system is flawless and fully meets your expectations. A multitude of factors must align to ensure an excellent patient experience.
Today, I present to you a clip of,
“A Glimpse into a Nurse’s Day” (GRB, 2024). You will witness how easily a mistake related to patient safety can occur.
Nurses bear the responsibility for the life of each patient they are assigned to, every single moment. But if one minor element goes awry, a patient who was prepared to be discharged from the hospital might never get to return home.
I invite you to share your insights on the manager’s question in the comments section.
Hello, my name is Damien. I see that you will be shadowing me today. Try to keep up as it will be a busy day. Also it is my 5th 12 hour shift in a row because we have been short staffed. Today we are down to nurses and I have a full assignment. I will start by assessing all the patients. I need to move fast and be as safe as I can when caring for my patients. Please try to stay behind me as I share my day with you. OK, let's go. Hello, my name is Carla. I am the manager of the inpatient unit you are visiting today. We are short nurses today so I expect it will be a busy day for everyone. I am confident that despite our current shortcomings, the nursing team is doing an excellent job at ensuring safe patient care. Our organization is reaching for zero patient harm this year and we are working hard to meet that goal. I hope you have a good visit. Hello Missus Drake. My name is Damien. I am your husband's nurse today. Last night he had a good night and his vital signs looked good this morning. Today, he is scheduled to go for a couple of walks with a physical therapist. He is now able to have a regular diet and will be receiving his last dose of antibiotics. I will be bringing that dose at 10:00 this morning. If all goes well today, he might get to go home tomorrow morning. Do you have any questions about his care for today? Hi Damien, The charge nurse mentioned you had a patient safety event. Please share with me what took place. Yes, Carla, I made a medication error. This morning I went into room 307 to give Mr. Drake his last dose of antibiotics that were due at 10:00 AM. I hung the medication at 10:25 AM. After a couple of hours I went back to remove the bag. When I did, I noticed that the patient name, the antibiotic and dose were all wrong. Carla, when I grabbed the bag from the medicine cart, I was positive I grabbed the correct bag. What is going to happen now? Today, unfortunately, a nurse made a mistake administering a medication. As a manager, there are various competencies that come into play when managing a situation like this. For example, an understanding of the severity of the error, soft and hard skills, communication skills, clinical skills, and emotional intelligence. Knowing how to successfully manage HR situations like this take experience and knowledge. Can you identify systemic reasons that lead to the nurse grabbing the wrong medication?
As you point out, this isn’t a “nursing” issue - it’s a systemic issue and pointing the finger at a severely under-resourced individual adds insult to injury and drives the problem underground.
80/20 Reimagineer | Where overcomplicators find possibility in simplicity
6moThis is incredible. Did you MAKE THIS Gina A. Ruiz-Brice, DHA©, MSN, BSN, RN?! My heart breaks for the hardworking nurses who are doing such an important job while being so insanely under resourced! Thank you for sharing this!