Dr. Cheryl Pollard PhD, RPN, RN

MacEwan University

Edmonton, Alberta, Canada

Consequences of Error:

Preparing nursing

students to practice in an

imperfect world

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Objectives

§ Explain the importance of understanding how healthcare professionals and students are effected when involved in patient safety incidents, adverse events or near miss situations.

§ Identify the estimated occurrence of student exposure and direct involvement with patient safety events.

§ Discuss common student reactions to being involved in a patient safety incident, an adverse event or a near miss situation.

§ Identification of how to support students after being involved in a patient safety event

Support Received

§ Grant/Research Support:§ MacEwan University

§ Research, Scholarly Activity and Creative Achievement Fund

§ Project Stream

§ Dissemination Stream

§ I have no actual or potential conflict of interest in relation to this program/presentation.

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Definition“An event or circumstance which could have resulted, or did result, in

unnecessary harm to a patient.” (p. 131)

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Patient Safety Incident

Canadian Patient Safety Institute. (2012) Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute.

4Image Source:

http://easymodules.net/Media/Default/Images/Blog/Orchard/why-hire-us.jpg

(Baker et al., 2004; Sears, Baker, Barnsley, & Short, 2013; Waterman et. al, 2007; Wu & Steckelberg, 2012)

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Our systems inevitably lead to bad choicesHancock, Trevor.Times - Colonist; Victoria, B.C. [Victoria, B.C]02 Sep 2018: D.8.

The Institute for Healthcare Improvement in the U.S. is a leader in improving the quality of care and the effectiveness of the health-care system, and its approaches are also widely used in Canada.

The guiding principle underlying all that the institute does is that "every system is perfectly designed to get the results it gets."

What's the one thing many of us Canadians take pride in about our country? Public healthcare. Canada is among the numerous countries that have public healthcare, but even our system has room for improvement. A public healthcare system is not a perfect healthcare system.

Canadian Medicare is not socialized medicineBrar, Noor.Prairie Post West; Swift Current, Sask. [Swift Current, Sask]23 Nov 2018: A.6.

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Whatever you call it, we know that patients and providers frequently conceal medical information from one another. Doctors, for example, might withhold information about bleak prognoses, their financial conflicts of interest or medical errors. Patients might misrepresent their alcohol intake and exercise.

Why patients routinely deceive their health-care providersScannellNews, Kate.The Spectator; Hamilton, Ont. [Hamilton, Ont]10 Jan 2019: G.7.

When the doctor says sorry; It's been a dozen years since healthcare apology laws came to Canada. Does it work?Thomas, Paul.The Tofield Mercury; Tofield, Alta. [Tofield, Alta]18 Apr 2018: A.4.

My introduction to the complex and emotional world of adverse events in health care occurred in 2001 when I chaired a committee to review an inquest report into the tragic deaths of 12 infants in a pediatric surgery program in Manitoba. Justice Murray Sinclair, who conducted the inquest, had concluded that at least five of the deaths were preventable.

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§ How many fourth year nursing students have been exposed to an adverse event or a near miss situation?§ Does each cohort have similar

experiences?

§ What types of adverse events or near misses do students experience?

§ What was their reaction to the situation?

§ What was the perceived reaction of others?

§ Was support provided to students who were involved in an adverse event or a near miss situation?§ What type of support has been

provided to nursing students who have been involved in an adverse event or a near miss situation?§ How effective was this support?

§ If this event were to happen to another student what type of support should be provided?§ How could/should this be

provided?

§ How could this type of adverse event be avoided or harm reduced in the future?

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What Happened

§ Medication§ Analgesic

§ Narcotic and Non-Narcotic§ Anticoagulants

§ Real dose vs prescribed dose§ Gave prescribed does in ER –

transferred to ICU§ IV

§ Rate§ Continuous vs intermittent§ No one noticed it should have been

discontinued – patient had CHF and transferred to ICU

§ Fall§ Patient helped to bed and didn’t

realize hip was broken – patient died

Reaction

§ Anger and frustration§ Directed at organization§ Directed at self

§ Fear about effect of reputation

§ Self-doubt

§ Decreased job satisfaction

§ Detachment

§ Sleep disturbances

§ Repetitive memories

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Information needs to come back

• Has this happened before• What strategies can be tried to reduce the potential occurrence• How successful have these strategies been

Teaching Objectives

• Reactions did not vary depending on what form was used• Training on what to do when involved in a patient safety incident has generally focused on

what paper/forms to fill out.

Self-care

• Reflective journaling

Breaking the Silence

• This has happened to others• Debriefing

Dr. Katrina Hurley is an emergency physician at the IWK Health Centre and research director in the division of pediatric emergency medicine in Halifax Nova Scotia.

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“Mistakes never really leave you.”

Reducing the

Stigma of Error

15Image Source:

http://powerofpositivity.net/wp-content/uploads/2013/02/footprints-21.jpg

§ Baker, G.R., Norton, P.G., Flintoft, V., Blasi, R., Brown, A., Cox, J., ... Tamblyn, R. (2004). The Canadian adverse events study: The incidence of adverse events among hospitalized patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686. doi:10.1053/cmaj.1040498

§ Sears, N., Baker, R., Barnsley, J., & Short, S. (2013). The incidence of adverse events among home care patients. International Journal for Quality in Health Care, 25(1), 16-28. Retrieved from http://intqhc.oxfordjournals.org

§ Waterman, A., Garbutt, J., Hazel, E., Dunagan, W., Levinson, Fraser, V., & Gallagher, T. (2007). The emotional impact of medical errors on practicing physicians in the United States and Canada. The Joint Commission Journal on Quality and Patient Safety, 33(8), 467-476. Retrieved from http://store.jcrinc.com/the-joint-commission-journal-on-quality-and-patient-safety/

§ Wu, A., & Steckelberg, R. (2012). Medical error, incident investigation and the second victim: Doing better but feeling worse. BMJ Quality & Safety, 21(4), 267-270. doi: 10.1136/bmjqs-2011-000605

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