Monday, September 04, 2006

The professional precipice

Have you ever had that moment of revelation, when you suddenly realise that you are walking dangerously close to the edge of a figurative precipice? One step further and you would be over the edge, falling into an abyss of your own making. All your best intentions cannot save you from the reality that you are not as noble and good as you once thought. An internal blackness you were not aware of has almost pushed you over the edge into a place you never envisaged approaching.

I had one of those moments last week. I was working with a graduate nurse when I observed her make a medication dispensing error.

Unfortunately this is not unusual – I frequently observe graduates making medication errors. Interestingly their excuse is nearly always the same. They blame their error upon my presence. They say that with me watching them they become nervous and forget to look up unknown medications, or they make calculation errors and dispense four tablets instead of two, or they mistake one drug for another. The power of a clinical support person is a little scary!

I pointed out this particular error, the nurse fixed the problem and the patient received the correct medication. A happy ending for all involved.

Except the story doesn’t end there. Our hospital policy dictates that all actual and near-miss medication errors must be reported. It wasn’t enough to point out the graduate’s error and ensure the patient received the right drug – I had to report this as a clinical incident. It’s a mean task and I don’t like it, but I'm required to do it!

I sighed deeply and asked myself if I really had to report this? On an imaginary scale of drug errors, this would have been minor. The patient would not have been harmed – they wouldn’t have received what was prescribed but it would not have resulted in any untoward event. And the graduate nurse was so nice. I’d pointed out her error, I’d suggested she slow down, pay more attention and check, check, check when dispensing medications, and she took this on board. What would it really matter if I didn’t report this?

And that was my precipice moment of revelation!

In Australia the Australian Nursing and Midwifery Council (ANMC) prescribe the competency standards that all nurses must work to. The regulatory bodies of Australia use these standards to determine a nurse’s competence and fitness for practice. I like to think I am not only a nice nurse, but that I am quite competent. If I held my practice up against these ANMC Competency Standards it would look good. Until last week, that is, when I realised that I was skimming dangerously close to the edge.

Competency Standard 2.1 states that I must “Practice in accordance with the nursing professions’ code of ethics and conduct.” This means that I must accept individuals regardless of race, culture, religion, age, gender, sexual preference, physical or mental state. I must ensure that my personal values and attitudes are not imposed on others.

I like to think of myself as a broad minded, accepting nurse – I don’t usually have a problem with following our Code of Ethics. Then I remembered a graduate I worked with last year. They had struggled with a number of clinical issues, and when the problems were pointed out they would not accept the assessment nor any advice, education or support. This was complicated by personality differences and it all became rather nasty. Consequently, if I observed the graduate making any medication errors I pointed them out and did not think twice about writing an incident form – it needed to be documented that this person was struggling.

So what was the difference between this situation and my current dilemma? Not much. I had observed both graduates making medication dispensing errors and they both corrected the problem prior to administering drugs to the patient. Hospital policy had not changed – in both situations I was required to report the incident.

The difference was that I really liked one person and didn’t want to report their mistake. The other person was difficult to work with so I had no problem reporting them. So much for practicing in accordance with a Code of Ethics! I was not wrongly treating somebody because I didn’t like them – I was wrongly treating somebody because I did like them. I wanted to protect them because they are a nice person.

I suppose this is only natural but it’s a bit shameful too. I cannot work in this job if I am so patently biased. This has been a wakeup call for me. Don’t be so concerned about being nice – be concerned about making accurate assessments and providing honest feedback. These graduates need people to be real with them. Their best chance at becoming competent is to hear about the fantastic things they do and to hear about the mistakes they make. Then they can grow and develop.

So I’ve walked away from the abyss, reported the incident and I’m making a commitment to being unbiased at all times in my support of graduates.


At Friday, December 01, 2006 2:04:00 pm, Anonymous Kim said...

Every single incident reported helps stregthen the system so that a particular error is less likely to happen again.

Even though it was a new nurse learning to think clearly on the job, everyone can learn from the near-miss.

I always appreciated it when someone talks about a near-miss or tells me about an error they made.

My practice became safer learning from those mistakes. Plus here, those errors (usually) don't result in any repercussions because they WANT the reporting done without fear of reprisal.

At Saturday, December 02, 2006 9:57:00 am, Blogger herschelian said...

I'm not in the medical profession, but I too have found myself teetering on the edge of not following required procedures (which I think can be onerous and counter-productive much of the time) just because I liked one trainee and yet didn't hesitate when I was dealing with a trainee I didn't warm to. You made the right judgement call, and you will probably now find it easier to detact yourself from personalities and just do what you have to do. This situation must occur frequently, and I have asked that it be raised in training sessions to try and help colleagues recognise the danger signals within themselves.

At Tuesday, December 05, 2006 1:36:00 pm, Blogger Judy said...

I think it's important to develop the mindset that reporting is about discovering system errors as much as it is about discovering personal errors.

If the errors are examined very closely and impartially, one discovers such things as similarly named, but vastly different medications which should never be stored near one another.

This is a battle I fight constantly in my unit. People simply do not want to report errors - theirs or anyone elses. They tend to view it as blaming, rather than seeking to make patient care safer in the long term.

I think we're finally making progress, though. After one recent, rather minor change, one of my co-workers surmised that it had resulted from an error somewhere else. Perhaps they will eventually realize that reporting errors in OUR unit can help to make things safer for everyone.

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