Medication Errors
Given that human errors should be considered as expected events, healthcare institutions are required to routinize processes aimed at the prevention of human error and limit the negative consequences associated with the error. One most common form of human error in the healthcare industry is medication error. In the United States, approximately 1.5 million patients are adversely affected by medication errors every year (Jones & Treiber, 2018). The provided case study demonstrates two nurses making medication errors, where one leads to adverse events whereas the other one does not.
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In such a situation, both the two nurses should face similar consequences. A just culture is considered a value-based culture that promotes shared accountability, hence demands that the situation be dealt with similarly. However, before deciding on which kind of punishment to give, an investigator must be involved, to determine the cause of the medication error, whether it was due to the system, negligence or the nurses just failed to pay attention to following hospital protocols (Jones & Treiber, 2018). Once the cause of the problem has been identified, a corrective measure should follow based on the outcome. This helps promote a sense of accountability, helping the nurse to avoid such errors in the future.
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Consequently, in a just culture, clinicians are required to share responsibility for promoting patient safety and the quality of care provided (Marx, 2019). As such, there should be no blame as to who caused the most damage, but rather, the nurses should both share the blame for making the medication error equally, and determine whether there were any system factors contributing to the error. However, if the nurse tends to undermine the hospital policy and frequently cause medication errors, then they should take responsibility for their action and suffer the necessary consequences.
References
Marx, D. (2019). Patient safety and the just culture. Obstetrics and Gynecology Clinics, 46(2), 239-245. https://doi.org/10.1016/j.ogc.2019.01.003
Jones, J. H., & Treiber, L. A. (2018, July). Nurses’ rights of medication administration: Including authority with accountability and responsibility. In Nursing forum (Vol. 53, No. 3, pp. 299-303). https://doi.org/10.1111/nuf.12252
Discussion Question:
Two nurses make a medication error: One causes an adverse event with a patient and the other does not. Should the nurses be disciplined, and, if so, should they be disciplined the same way? Why or why not? How would this be addressed in a just culture?
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