Nobody likes that coach who plays favorites. Having a spot on the starting lineup should be earned, not just given because the coach likes you. The best possible scenario (winning) can only be accomplished by putting forth the team’s best effort (playing those who’ve earned the spot).
Wouldn’t you agree?
The same can be said about the role of Quality Improvement (QI) in our profession. Don’t worry, I’ll connect the dots!
Optimum patient care can only be accomplished by putting forth our best effort as a health care team. Our best effort means correcting and improving upon scenarios that were not optimum. I don’t think anyone would argue that events like medication errors, patient harm near-misses and unfortunate mistakes are not what we would consider optimum in the world of health care.
Enter QI.
I remember during a hospital orientation someone made the comment, “QI is everyone’s responsibility.” I couldn’t agree more.
When there is an error in the process, we need to report it. How else are we to determine what happened? How else can we investigate, fix and hopefully prevent the error from happening again?
When a fellow coworker makes an error, a reportable incident that can, could, or did cause patient harm, it needs to be reported.
And here lies the problem.
Unfortunately, nurses are playing favorites like that coach I talked about earlier. If they like the person who made the error, they won’t report it. If they think that person is “nice,” or “didn’t do it on purpose,” they don’t report the error.
Hmm?
While I love our show of support and camaraderie for our fellow coworkers, we must not view our QI duty as if we are turning our backs on those nice people. While being nice is great, being good at your job is how we take care of our patients. While be liked is nice, performing at our best is what our patients deserve.
Nobody likes a snitch, but consider how many incidents have not been reported due to this fear of offending someone we like. The last time I checked, ignoring a problem doesn’t make it go away.
Have you encountered similar experiences? Any thoughts on how to fix this problem? Share your thoughts in the comments section below.
This article was republished with permission from SCRUBS Magazine.
Accountability is empowering. Acknowledge your mistake, own it and work to correct it with help from peers and administrators. To err is human…to forgive is divine!
in my 35+ years in nursing, What I have seen time after time is that, punitive actions are taken ALWAYS. In other professions, they so rarely report their own and in fact protect each other, that it is foolish to think that we should hurt each other in this way, if there could be an employee council to address these issues, that would be a positive step , but my experience has been that repeatedly those that are not liked are disciplined ( e.g., complaining of unsafe patient loads, mandatory overtime, lack of management intervention when appropriate and etc,). There is a ever widening disconnect between those who have to do the job and those who don’t , we are the ( only?) profession having little to no control over our day and are held to a standard that many times may literally be impossible and then held to account why something went wrong. Until this changes…
Bottom line, I found in over 40 years of emergency nursing that the QI folks are in the pocket of administrators and although they give lip service to the fact that they are not punitive when a nurse makes a mistake, the reality is that they need a scapegoat and the nurse is the nearest target. The hospital lawyers and liability insurance administrators also play a role in hanging the nurse out to dry.
Unfortunately the profession especially management and administration are nothing if punitive. It would not be a “learning experience ” for that Nurse that may have made a mistake. QI has a habit of only looking at WHAT the mistake was and WHO made the error not why it occurred, the nurse may have worked a double shift most likely with little or no break; probably had too many patients or could have been mentoring a new nurse. With 30 years of experience I could give you a litany of things that may have contributed to the mistake. What ends up happening is the nurse gets reprimanded or worse. And the mistakes repeat themselves. In my experience nurses aren’t eating themselves rather administration is. Errors should be treated like they are with physicians in teaching hospitals-completely anonymous.
I totally agree with you! Nurses are the ones reprimanded or worse by administrators that have little to no knowledge of what the nurses work day is like. A nursing council, made up of unit nurses, to be fair, could be utilized to review errors and make recommendations for errors to be a learning experience.
If a nurse is impaired or totally incompetent then yes but otherwise no. We need to support each other. Everyone makes mistakes. the authors logic about not reporting people you like works both ways. Some nurses will attack other nurses with petty reporting. Old school nurses not only eat their young ( and inexperienced) they eat each other. The author is obviously a manager who probably didn’t spend a lot of time in the trenches.
Rather than being a “snitch”, I have found better results with talking directly with the person who made the error and giving them the chance to report themselves. Discussing the issue and even doing a short debrief often works in letting the person know things do happen but also talk about the consequences that may follow if not reported. In many cases reporting the issue acts as CYA in case of legal or ethical ramifications as well as a boost in integrity and honesty. I know I would not have any problems working with a person of integrity if they owned up to their misjudgements.
Often times nurses want to report, however the process itself is so ponderous and time consuming it becomes impossible. With staffing so tight that nurses are struggling to take care of patients needs and the cutback in ancillary staff, and the requirement to not stay overtime to complete reporting nurses choose to use their time taking care of their patients. The options often aren’t available to stop and fill out a multi page document that may or may not be acted upon. Also a common statement amongst nurses about why they didn’t report is, ” I have and nothing changes or there are no consequences.” The QI results do not come back to the initial reporting person. Or if there is a response it is so far past the initial event that no one is even aware that this change is related to a specific event. We big everything down with meetings and committees that the “cause and effect” gets lost.
Many processes, especially new ones, have flaws to begin with. The importance of reporting is essential in that case. You have to then review the process and see where did this occur, what portion needs to change, or is it that the staff were not properly educated on it, or was the educational tool ineffective, do we need some sort of tool to help remember the process’s steps, etc. It is not about getting someone in trouble or getting someone one fired, it is about looking at things and seeing patterns, patterns that can either be changed by improving a process or working with that staff person to teach them how to change their pattern, or if they really are not capable moving them to another area they can handle or terminating them. Not reporting creates as much of a liability as the error itself did!
This is a tough call and often it’s the reporter that has to go as well. Then there is our community responsibility if you have a neighbor going child abuse. Once you take on the credential it comes with much.