NUR 4102 Module 6 Errors Paper: Human Factors, Just Culture and Disclosure Example

Two Pens, One Patient: Responding to an Insulin Error With a Just Culture

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4102: Leadership and Management in Nursing: Scholars Track

Mentor Name

Month Day, Year

Two Pens, One Patient: Responding to an Insulin Error With a Just Culture

The Error

Mrs. Harris, an invented 68-year-old admitted for a foot infection on top of type 2 diabetes, was due for 10 units of rapid-acting insulin before lunch. Her nurse gave the dose and was immediately called to a rapid response down the hall before she could finish documenting it. A float nurse covering her patients saw the lunch tray arrive, checked the electronic medication record, which still showed the dose as due, and gave a second dose from a pen kept in a different drawer. Forty minutes later Mrs. Harris was sweating and confused, with a blood glucose of 48. She received dextrose and recovered completely.

Two Ways to See Error

Reason (2000) contrasted two ways organizations think about mistakes. In the person approach, the unsafe act is blamed on the individual's forgetfulness, inattention or weak motivation, and the remedy is naming, retraining or discipline. In the system approach, human fallibility is taken as a given, and attention goes to the conditions under which people work and the defenses that should catch their slips. His familiar image compares those defenses to slices of Swiss cheese stacked together: every slice is imperfect, and harm reaches a patient only when the holes in several slices happen to align and let a hazard pass through. Blaming the person at the sharp end, he argued, leaves those latent holes in place for the next clinician.

The Scale of Harm

The Institute of Medicine's report, edited by Kohn et al. (2000), estimated that medical errors were responsible for somewhere between 44,000 and 98,000 hospital deaths in the United States each year. Its authors maintained that the main problem was not careless individuals but poorly designed systems, processes and conditions, and they urged health care organizations to make the safe action the easy one and the unsafe action hard. They also called for reporting systems and a culture in which mistakes are surfaced and studied instead of concealed.

What Patients Want

Gallagher et al. (2003) convened separate focus groups of patients and physicians to learn how each group viewed error disclosure. Patients said they expected to hear about any error that caused them harm, and they wanted to know what went wrong, why it happened, how its effects would be managed and what the hospital would do so it would not happen to someone else. They also wanted an apology. The physicians supported disclosure as an idea yet worried about lawsuits and tended to choose their words with great care, which patients could hear as evasive.

Finding the Holes

Applied to Mrs. Harris's care, Reason's model showed several holes in a row. Documentation lagged because her nurse was pulled into an emergency. The brief handoff to the float nurse did not mention that insulin had already been given. Two insulin pens for the same patient were kept in two different drawers. The electronic record did not show that a pen had been scanned. The float nurse was working an unfamiliar assignment on an unfamiliar unit. Any one of these defenses working would have stopped the second dose.

A Just Culture Response

A just culture separates three kinds of behavior: human error, an unintended slip like this one; at-risk behavior, such as habitually skipping a check because it seems unnecessary; and reckless behavior, a deliberate choice to ignore a significant and unjustifiable risk. Each calls for a different response, consoling for error, coaching for at-risk choices and sanctions only for recklessness. The float nurse made a human error inside a system that had set her up to fail, so the right response was support and repair, not discipline. I met with her privately, listened, told her the event would be reviewed as a system problem and connected her with the employee assistance program, because clinicians involved in harm often carry real distress afterward.

Disclosure

Following what Gallagher and colleagues found patients want, the attending physician and I, with the float nurse's agreement, sat down with Mrs. Harris and her daughter that afternoon. We told them she had been given an extra dose of insulin, that this had caused her low blood sugar, that we were sorry and that we were changing how insulin is stored and recorded on the unit. Her daughter thanked us for telling them directly instead of letting them find out later.

System Changes

The unit made four changes. Each patient now has a single insulin pen kept in that patient's labeled bin. Every pen is scanned before each dose, and the record warns the nurse if the patient has had insulin within a set window. The handoff sheet has a required insulin line. And a nurse called away in the middle of a medication pass either documents insulin before leaving or tells the covering nurse in person.

How the Staff Reacted

Not everyone welcomed the just culture response at first. A few nurses felt the float nurse had escaped consequences, and the float nurse herself expected to be written up. I explained the difference between error and recklessness at two staff meetings and shared the list of system holes we had found. Several nurses then reported near misses with insulin pens that they had never mentioned before, which suggested that the unit was beginning to trust the reporting system.

Legal and Ethical Duties

Nurses have a legal duty to report errors through the hospital's reporting system and to document what happened accurately and honestly, without altering earlier entries. The American Nurses Association's code of ethics supports honesty with patients and a commitment to their safety. Disclosure handled well also tends to preserve the trust between patients and the people caring for them.

Limits

The Institute of Medicine's death estimates have been debated. A just culture is credible only when leaders apply it consistently over time. The patient and unit are invented.

Conclusion

Reason showed that the float nurse's error was the last hole in a line of system weaknesses, the Institute of Medicine called for systems that make errors hard and a culture that learns from them and Gallagher and colleagues showed that patients want honest disclosure and a plan to prevent a repeat. Supporting the nurse, telling Mrs. Harris and her daughter the truth and redesigning insulin storage and documentation put a just culture into practice.

References

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001-1007. https://doi.org/10.1001/jama.289.8.1001

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768