Most nurses fear making a mistake above all else. Maybe it’s because we know how easy it is to make a serious error, and can only imagine how devastating it would be.
Currently, Radonda Vaught, RN, is in the news and facing criminal charges for a mistake that caused her patient to die. Radonda is the nurse from Vanderbilt who mistakenly gave a 57 yr. old woman undergoing a PET scan Vecuronium, a paralytic, instead of Versed, a sedative. Her patient died from not being able to breathe.
Then there’s Kim Hiatt, from Seattle Children's Hospital NICU. Kim had worked there 24 years and by all accounts was a dedicated, compassionate nurse with a heart for families.
On September 14, 2010, Kim received a verbal order to administer 140 milligrams of calcium chloride IV to her patient, a nine-month-old. Kim made a tragic and deadly medication error when she gave 1.4 gms instead of 140 mgs.
Hours layer, the mistake was discovered when the baby’s heart rate was racing. A lab blood level of calcium chloride revealed abnormally high levels. The nine-month old baby died 5 days later. It is not clear how much the error contributed to the death as the baby had severe heart problems and was described as frail.
Kim was immediately ordered to leave, escorted out of the facility, and subsequently fired. Placed on probation by her nursing board, she was ordered to give meds “under supervision” only. Kim committed suicide seven months later in the basement of her home.
Somehow, as nurses we believe we’re supposed to make zero mistakes. This despite the Institute of Medicine’s 1999 Report ‘To Err is Human”. Given the right (or perhaps wrong) set of circumstances, we are all capable of mistakes. There is actually science around how our brains work and sometimes set us up to make errors. Here are some proven ways the science of making mistakes happens.
Inattentional blindness is not blindness associated with visual impairment. Inattentional blindness is a lack of attention when your brain is on autopilot, such as driving home after work, and not remembering the drive. It causes us to miss or misinterpret something right in front of our perfectly functioning eyes. It’s not about our eyesight; it’s about our attention.
There are limits to human attention capacity and perception. The disturbing thing is we are not consciously aware of inattentional blindness when it is occurring. That is why pharmacies sometimes use blister packs to dispense daily medications. It’s possible to take a pill on autopilot and not be sure it was taken.
Likewise, it is possible to connect oxygen tubing to a medical air outlet instead of to the oxygen outlet when performing a routine task such as assisting a patient back to bed.
Confirmation bias is seeing what we expect to see. Also, called selective attention, or divided attention, the phenomenon is best described when a group of radiologists was asked to view a chest X-ray for signs of cancer. When you are fully concentrating on something, you are paying attention to it to the exclusion of other things in the environment.
In fact, the X-ray was incidentally missing a clavicle and the majority of radiologists did not identify the missing clavicle. Why? The radiologists expected to see a clavicle, and therefore did not notice when it was missing.
A radiology nurse mistook the symbol “C-IV “on chloral hydrate syrup, a sleeping medication, for “IV” and almost administered it to a patient. Fortunately, the required independent double check made it a near miss and not a deadly mistake.
A classic example of distraction causing an error was recorded several years ago when a nurse poured chloral hydrate for a patient. She walked down the hall to the patient’s room carrying the medication in a medication cup. On the way, she stopped to talk with a physician, and while chatting, raised her hand and shipped from the chloral hydrate- as if it was coffee.
She was accustomed to holding her coffee cup in the same hand and reverted to routine when in a conversational situation. She had to be driven home to sleep.
Being out of routine is what caused the death of a toddler in a car recently when her NP mother drove to work, forgetting to drop her daughter off at daycare. The mother didn't notice until her work day was over 8 hours later, and the toddler died. The mother had her mind focused on work, her child out of sight in the back seat, and was out of routine- the father always drove the child to daycare.
Kim Hiatt, the nurse above who committed suicide explained her error “I was talking to someone when I drew it (calcium chloride) up. I’ve given calcium chloride for years”. Our brains are not designed for multi-tasking.
Doctors and nurses constantly click past overrides and pop up alerts. Search fields auto fill after only two characters and alarms are ignored because of nuisance alerts. The chaotic environment of hospital nursing sets nurses up to NOT be mindful. Nurses constantly juggle competing distractions and must guard against alarm overload.
No one intends to make an error or harm a patient. It’s rarely recklessness that causes human error and nursing mistakes. We’re all subject to inattentional blindness, distractions, and alert/alarm fatigue. It’s important to be vigilant and mindful of these dangers to our safe practice. When mistakes do happen we need to support each other and learn from the experience, creating a just culture.
References
Potchen EJ. Measuring observer performance in chest radiology: Some experiences. Journal of the American College of Radiology. 2006;3(6):423–432. [PubMed]