In my first year of nursing, I had an eight-year-old patient in my pediatric oncology unit who had just completed his last round of chemotherapy. I disconnected the IV tubing, flushed his implanted port, did the discharge paperwork, and he left for his celebration party. Driving home from work that night, I suddenly had a sinking feeling when I realized I flushed the port with a pre-prepared syringe of normal saline instead of heparin.

I was instantly faced with a quandary. The error wasn’t that serious because no significant harm would come to the patient. On the other hand, the port would likely clot, requiring surgery to remove and replace if it was needed in the future. That meant anesthesia…and recovery…and insurance payments…and physical pain for the patient. But ports clot all of the time, I told myself. No one would think twice if it happened. No one had to know.

When I arrived home, I called the boy’s mother. I could hear the celebratory sounds in the background and started crying when I explained what happened. I assured her that her son was not in immediate danger and could enjoy the party but he needed to go back to the hospital afterwards for the heparin flush. I then called the unit to let them know I had made a mistake and the family would be driving for two hours back to the hospital for a 10 second treatment that required submitting the boy to yet another large needle to access the port.

I was terrified to go to work the next day, convinced that I would either be fired or put on probation. Not to mention the grief I would have to deal with from the “nurse bullies’’ who were already snide when I asked a question or needed help. I was convinced they would eat me alive!

The manager surprised me by commending my actions and praising me for admitting to the mistake. Most of the nursing staff was supportive but, as expected, the bullies never missed an opportunity to crack a joke at my expense whenever someone grabbed a heparin flush, no matter who was in earshot. However, I was never asked to complete an incident report and the issue of the adverse drug event (ADE) I had caused was never discussed again.

Missed opportunity
Years later, I look back on this minor incident and the various opportunities it presented management to make it a learning experience, which they chose to ignore. Unfortunately, mine is not an isolated case.

ADEs continue to be the leading type of non-surgical adverse event occurring in hospitals in the U.S. This fact becomes even more chilling when you realize it doesn’t even tell the whole story. It has become normal hospital culture to not report ADEs when the patient has not been harmed. The Institute for Healthcare Improvement (IHI) estimates that only 10-20 percent of ADEs are voluntarily reported.[1]

To relentlessly pursue a culture of safety and strive to get to zero ADEs, each facility must track and collect data on allADEs. This is the only true way to select and test changes to reduce harm. The Joint Commission describes a robust safety culture as characterized by communications founded on mutual trust, shared perceptions of the importance of safety, and confidence in the efficacy of preventative measures.[2]

Appropriate ways to deal with ADEs
My experience provides a number of examples of how my entire unit mismanaged the situation and ways in which ADEs should be handled.

Develop immediate action procedures. Once I realized I had made the mistake, I had no idea what to do. I did not know the proper chain of command nor whom to contact since it was after normal business hours. The patient’s mother was likely not the best choice as the first point of contact! The IHI recommends adverse drug event drills to allow staff to practice their response to an ADE in a safe environment and to improve reactions when a real ADE occurs. IHI suggested procedures include rotating simulation drills to include all departments, shifts, and days of the week, as well as discussing the drills afterwards with staff to identify lessons learned. The feedback and learning from the drills should be shared throughout the organization.[3]

Establish a post ADE conference. My manager did not hold a de-briefing with me after the event to identify how or why I used a normal saline flush instead of a heparin flush. There was no root cause analysis to determine why the mistake occurred. Did I simply grab the incorrect syringe? Why didn’t I scan the pharmacy-labeled barcode? Was there a barcode? One study cited lack of feedback after an event as the most common reason that both physicians (57.7%) and nurses (61.8%) fail to report ADEs.[4] In a separate study, only 33.5 percent of pharmacists recalled receiving feedback about errors they had reported.[5]

If a healthcare professional is willing to acknowledge his or her own mistake and take precious time during a busy shift to complete a report, the organization must follow-up and investigate how and why the event occurred. Employees should be lauded for their willingness to step up and admit errors and be recognized for their desire and commitment to increase patient safety.

Require incident reports on every ADE. I assume because no harm was done to my patient it was not considered an actual ADE so I was not required to submit an incident report. One study reported that nearly half of healthcare professionals do not report ADEs if no harm to the patient has occurred.[6] Another report indicated similar attitudes towards “near-misses” in that physicians report them 42.1 percent of the time and nurses report them 41.9 percent of the time. The rationale offered was that there was “no point” in reporting near misses or that the incident was deemed “too trivial”.[7]

Unfortunately, in my situation, this was a lost opportunity to learn the cause of the error and how to prevent it in the future. Perhaps the pre-filled normal saline and heparin flush syringes were stored in the same area of the medication room, which caused confusion but could easily be addressed. Perhaps the pre-filled heparin flush syringes were not bar-coded by pharmacy, so I did not scan them. Perhaps I was overwhelmed with my assignment and it was too much for a newly graduated nurse to juggle. I’ll never know what caused the oversight because it was not considered dangerous enough to report or warrant investigation to ensure future prevention.

Establish a culture of safety. Admitting mistakes is never easy, but organizations can make it less difficult to do by establishing a non-punitive culture for reporting adverse drug events and near-misses. There has been extensive progress in this area with hospitals actively encouraging employees to complete incident reports with promises of no punitive action from management. But has the culture changed in regard to colleagues’ perceptions of a medication error or near-miss? The nursing profession continues to have difficulty addressing bullying of new nurses, which increases the likelihood that a new nurse will fail to ask for help or report an error. Disrespectful behavior by physicians has also been cited for lack of collegiality and cooperation, undermining of morale, and inhibiting transparency and feedback.[8]

The American College of Healthcare Executives recommends establishing organizational behavior expectations, starting at the C-suite, to establish psychological safety in the workplace in order to prioritize respect, transparency, and teamwork.[9] How many ADEs could be averted if healthcare providers were not ashamed to ask for help? How many ADEs are not reported due to the pervasive bullying culture?

The imperative to “Get to Zero”
As healthcare providers, we have committed our lives to caring for our patients and ensuring their safety. It is essential to learn from our colleagues’ mistakes and near-misses in the hopes of preventing a repeat ADE from occurring. An error is heartbreaking and causes feelings of self-doubt, shame, fear, embarrassment, and guilt. Significant errors causing patient deaths have even led some colleagues to commit suicide.

Organizations must inspire a culture of safety and embolden employees to report any ADE, regardless of severity, so that we all can learn from the mistake. An ADE stays with a clinician forever, as evidenced by my recollection of a relatively minor event that occurred more than a decade ago.

One ADE is too many. It’s tough to be perfect, but we must learn from mistakes, collect all relevant data and take appropriate corrective actions. With a supportive and understanding culture and by providing new technology tools to help our dedicated caregivers treat patients safely, we can “get to zero” ADEs. It’s certainly a goal worth pursuing.

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[1]Conduct adverse drug event (ADE) drills, Institute for Healthcare Improvement website, 2018

[2]The essential role of leadership in developing a safety culture, Sentinel Event Alert, Publication byThe Joint Commission, 2017

[3]Conduct adverse drug event (ADE) drills, Institute for Healthcare Improvement website, 2018

[4]Attitudes and barriers to incident reporting: A collaborative hospital studyby S. M. Evans, J. G.  Berry, B. J. Smith, A. Esterman, P. Selim, J. O’Shaughnessy, & M DeWit, BMJ Quality & Safety, 2006

[5]Perception of reporting medication errors including near-misses among Korean hospital pharmacists. By Medicine, by H.-J. Kang, H. Park, J. M. Oh, & E.-K. Lee, 2017

[6]Perception of reporting medication errors including near-misses among Korean hospital pharmacists. By Medicine, by H.-J. Kang, H. Park, J. M. Oh, & E.-K. Lee, 2017

[7]Attitudes and barriers to incident reporting: A collaborative hospital studyby S. M. Evans, J. G.  Berry, B. J. Smith, A. Esterman, P. Selim, J. O’Shaughnessy, & M DeWit, BMJ Quality & Safety, 2006

[8]Perspective: A culture of respect. Part 1: The nature of causes of disrespectful behavior by physicians, by L. L.  Leape, M. F. Shore, J. L. Dienstag, R. J. Mayer, S. Edgman-Levitan, G. S. Meyer, & G. B. Healy, Academic Medicine 2012

[9]Leading a culture of safety: A blueprint for success, American College of Healthcare Executives, 2017.