Two nurses make a medication error: One causes an adverse event with a patient and the other does not. Should the nurses be disciplined, and, if so, should they be disciplined the same way? Why or why not? How would this be addressed in a just culture?
Solution
As per (Rogers et al., 2017) Medication errors continue to be a concern of healthcare providers and the public, on how to prevent harm from medication mistakes. Many health care workers are afraid to report errors for fear of retribution including the loss of professional licensure and even imprisonment. Most healthcare workers are silent, instead of admitting their mistake and discussing it openly with peers. This can result in further patient harm if the system causing the mistake is not identified and fixed; thus, self-denial may hurt patient care outcomes. As a result, pharmacy leaders, in collaboration with others, must put systems in place that serve to prevent medication errors while promoting a “Just Culture” way of managing performance and outcomes.
Both nurses who made medication errors should be investigated and receive disciplinary action, but the discipline should not be the same. Instead of focusing on only the outcome, the main point should be the intent and flaws in the system behind the error. I think that the nurse who caused the adverse effect will probably face more disciplinary action than the other nurse who would probably receive education and system-focused interventions to prevent making future errors. The just culture approach in this case is behavior. What were the steps taken before the error? Did they follow the proper procedure? Were they aware of the potential risks?
An investigation to determine the root causes should be started and examined to identify the issues that contributed to the errors. An origami can be completed with detailed documentation about the events that led to the error, as this can help them receive proper feedback and more training. Origami can also help create a new system process to put in place to prevent future errors like these. The nurse who caused harm will probably have written reprimand, suspension, and even jail time if the circumstances around the error find it appropriate.
Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A Just Culture Approach to Managing Medication Errors. Hospital Pharmacy, 52(4), 308. https://doi.org/10.1310/hpj5204-308