PS 104:

Vincent et al. go on to identify seven categories of factors that influence clinical practice and medical error. In any given situation, one or more of these can be involved

• Institutional Context
• Organizational and Management Factors
• Work Environment
• Team Factors
• Individual Staff Member
• Task Factors
• Patient Characteristics

(PS 104)

contributory factors.

Within each of these categories, multiple opportunities exist for failures that can lead to errors. Vincent calls these opportunities “contributory factors.” In any given situation, typically a number of contributory factors are at play.

Attending to the seven categories of contributory factors while analyzing an incident, Vincent suggests, allows us to “examine the whole gamut of possible influences.”

In fact, Vincent doesn’t like the term “root cause analysis” at all, preferring the term “systems analysis

they are retrospective;

they look back at an error that occurred, often from several perspectives – from the viewpoint of the patient, provider, nurse, supervisor, etc. In this situation, the office manager seeks to prevent error prospectively, before it happens.

not appropriate in cases of negligence or willful harm. These cases are better investigated by the police

Root cause analysis is a type of incident analysis used after an adverse event or a near miss in which willful negligence did not occur. It takes a broad approach to error prevention rather than blaming the individuals involved. It is useful for identifying areas for improvement to prevent future adverse events, and it can help channel the energy that accompanies an accident by turning an error into a learning opportunity. Overall, the purpose is to find out what caused an adverse event and how to prevent a similar error from happening in the future.

(PS 104) An office manager and her staff are opening a new pediatric clinic in a medical office park. She looks around the waiting room and sees uncovered electrical outlets, tables with sharp edges, and a beautiful porcelain vase on a thin wrought-iron pedestal. The office manager begins to worry that the waiting room may not be safe for rambunctious toddlers.

Would an RCA be useful in this case?

A resident in anesthesia slips partially used bottles of sedatives, narcotics, and anesthetics from the operating room and pain clinic into his pocket when his supervising attending isn’t looking. He takes them home for his own use. Later, his roommate finds him passed out and not breathing on the couch in their apartment.

would an RCA be useful in this case?

Dr. Jones is having a very busy day in the internal medicine clinic. The printer that he uses to print computerized prescriptions for his patients is out of ink. He is already running 45 minutes behind but is trying to take good care of Mr. Diaz, who has hypertension and diabetes. Dr. Jones quickly hand-writes a prescription for an antihypertensive and gives it to Mr. Diaz. The pharmacy misreads the prescription and dispenses a dose 10 times greater than Dr. Jones intended. Later that evening, Mr. Diaz gets dizzy and falls down the stairs.

Would an RCA be useful in this case?

a) They help to assign blame.
 b) They help to identify system failures that can be corrected.
 c) They are often quick and simple to perform.

Correct Answer:b) They help to identify system failures that can be corrected.

Root cause analyses are systematic approaches to understanding an error (or a near miss), with the hopes of identifying systems failures that can be addressed. They are not used to assign blame, nor are they necessarily quick. They are retrospective, occurring only after an error has happened.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle.

a) The nurse did not listen to the patient.
b) The patient was male.
c) The hierarchy in the operating room had a negative effect upon communication.
d) In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one.

Correct Answer:c) The hierarchy in the operating room had a negative effect upon communication.

RCAs are meant to identify system failures that might place patients at risk for similar errors in the future. Poor communication due to hierarchy is one such reason. The nurse’s failure to listen to the patient would be a symptom of the larger, “big-bucket” problem.

Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle.

a) Patient characteristics
b) Team factors
c) Individual team member
d) Organizational and management factors

Correct Answer:d) Organizational and management factors

When conducting an RCA, it is important to take a balanced look at errors. Charles Vincent identified seven categories of factors that influence clinical practice, including the four above. All seven should be considered when conducting an RCA. The pressure to complete surgeries on time most likely has its origin in organizational and management decisions.

 a) An occupational therapist quits after only three days on the job.
b) A physician is convinced that there is a better way to deliver pain medications on her unit.
c) A social worker catches a patient who is falling out of bed.
 d) An administrator needs to develop a balanced budget.

Correct Answer:c) A social worker catches a patient who is falling out of bed.

RCAs can be very useful in health care to address both errors as well as near misses, such as the near-fall in answer choice C.

a) Use categories to organize events that led to errors.
b) Focus on a single process in order to consider it in depth.
c) Consider the costs involved in addressing the problems found during the process.
d) Avoid focusing on patterns.

Correct Answer:a) Use categories to organize events that led to errors.

In an RCA, we group the events that led to the error (or near miss) into categories, so that the most important and crucial work processes can be addressed. Discerning patterns of this kind is important, as is considering a broad range of processes from which problems might have arisen. Although costs may need to be considered later on, this is not part of an RCA.

1. Understand the system failures that led to a specific adverse event. 
2. Prevent a similar adverse event in the future.

The team should be interprofessional, and it should include individuals at all levels of the organization who are close to and have fundamental knowledge of the issues and processes involved in the incident.

In addition, members of the risk management and/or quality improvement departments are helpful to have on the team, as they can often provide an unbiased view of the incident and serve as a facilitators

It is also important that the clinical and administrative leaders in the hospital are supportive of the RCA and provide time and resources for the RCA to be completed. RCAs require a considerable amount of time and work and may lead to many ideas for process improvement; team members often need to be relieved from some of their usual duties so they can focus on this work. While leaders can lend their support also by participating on the team, this is not necessary. What is required is a commitment to support the members who are on the team and help them participate fully.

Experts agree and disagree about whether to use the patient or family members or people involved in the event

1. Team Leader: an individual familiar with RCA methods and processes who can guide the team toward completing tasks
2. Advisor: an expert either in the area of health care being discussed, or in RCA
3. Recorder: someone who keeps track of the information gathered, charts made, and lessons learned
4. Team Members: other participants in the process

1. identify what happened

2. review what could or should have happened

3. determine causes

4. develop causal statements

5. generate a list of reccomended actions to prevent reoccurence of the event

6. write a summary of leadership, staff, and others involved in the event

information gathering phase

the team must try to describe what happened accurately and completely. The better the team can define the event, the more focused and appropriate the ultimate improvement efforts can be. A team should start with outlining their initial understanding, the basic story of the event. This might come from an incident reportAn incident is an adverse event or serious error. It’s also sometimes referred to as an event.

[Source: When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; March 2006.]

An incident report is an objective summary of the facts of an event, completed by the individuals involved. Most health care organizations require some type of written account of near misses and incidents of patient harm. An incident report should be completed as soon after the incident as possible. or what the team members themselves already have heard about the event. 

Discrepancies between team members’ understandings or gaps in the chain of events are fine – these point to what they need to find out in person.

Next, to really nail down what happened, team members must collect more information on the event. This can be done in a variety of ways, including by walking through the areas involved in the event, interviewing staff in these areas, observing patient flow, talking with others in the locations where the event occurred, and reviewing the medical records

Focus on WHAT HAPPENED and not WHY it happened-encourages open communication

To organize and further clarify information about the event, the team creates a high-level flowchart. This is a simple tool that allows you to draw a picture of what happened in the order it occurred

This may involve reading through hospital policies, reviewing medical literature, or interviewing department directors to find out about barriers to safe practice

After the team collects information about what should have happened, they create another flowchart of the event, showing how things should have occurred if the hospital had had reasonable procedures and the caregivers had complied with them:-example, in the case of margaret peter should have given hand off and there should be a procedure in place to put a sticker on the patient’s chart

Step 3 of RCA: Determine causes “Ask why 5 times”

Heart of the RCA

This is where the team determines the factors that contributed to the event. Based on these factors, the team can plan improvement projects and strategies.

When examining an event, teams identify both direct causes and contributory factors

After asking these four questions, the team finally gets to a root cause of the problem: standard operating procedures for clearing do not exist. This is a cause that, if addressed, can possibly prevent the event from occurring again.

This example is fairly straightforward and involves only four questions. In complex RCAs, multiple “ask why five times” exercises may be necessary to identify the multiple factors contributing to a problem.

fishbone diagram

Sometimes called an “Ishikawa” or “cause and effect” diagram, this is a graphic tool used to explore and display the possible causes of a certain effect

Negative event in middle-each rib representing one of vincents 7 categories

Step 4 of RCA: develop causal statements

We can “construct cause” by writing causal statements. A causal statement links the cause (identified in Step 3) to its effects and then back to the main event that prompted the RCA in the first place. By creating causal statements, we explain how the contributory factors – which are basically a set of facts about current conditions – contribute to bad outcomes for patients and staff

People are not causes but rather actors

1.       The cause (“This happened…”)

2.       The effect (“…which led to something else happening…”)

3.       The event (“…which caused this undesirable outcome

The lack of standard operating procedures and documentation for clearing the area [the cause] increased the likelihood that sharps would be left out [an effect] , which increased the risk that Clara would cut her finger [an effect], which led to the need for stitches and lost work [the event].”

lead to actionable improvements

·         Root cause statements must clearly show the “cause and effect” relationship.

·         Statements should include neutral language and not imply judgment or blame. 

·         Each human error must have a preceding cause.

·         Violations of procedure are not root causes; they must have a preceding cause.

a) Include Quinn’s parents.
 b) Put together a team of mostly nurses and physicians.
c) Create a team of members who fulfill several roles.
d) Include the health care providers involved in Quinn’s care.

Correct Answer:c) Create a team of members who fulfill several roles.

Root cause analysis teams need to be diverse in order to be able to see as many viewpoints as possible. While patients and families, as well as the providers involved, may be included in the teams, there is by no means consensus about whether to include these individuals. Interprofessional teams are strongly encouraged, but there is no hard-and-fast prescription for which professions should be included or what the balance of the professions should be. Ideally, the team will include people with a strong understanding of the areas and processes involved in the case.

a) Wait to conduct the RCA for a period of time, in order to let the emotions surrounding the incident subside.
b) Make sure that the team conducting the RCA is clear about what they can and cannot review from the records.
c) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary.
d) Make sure there is at least one member of the senior leadership on the team.

Correct Answer:c) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary.

Conducting a high-quality RCA takes time and resources, and it is important that leadership makes sure these are both available to the team members. Senior leadership does not need to be on the team itself, and senior leaders may even be an impediment to drawing candid answers out of front-line staff. RCAs should be conducted quickly, before memories fade and attention is turned to newer problems

) The team conducting Quinn’s RCA begins work. What should their first step be?

Correct Answer:b) Review Quinn’s medical records and interview providers.

The first step of an RCA is to identify what happened. This can be done by reviewing charts and records, and by interviewing the patient, family, providers, and any other relevant personnel. Reviewing literature and developing causal statements are part of an RCA, but they occur later in the process. Obtaining opinions might be helpful, but this is not a standard part of the RCA

a) Understanding what led to an error requires diverse perspectives.
 b) A team helps the RCA move more quickly.
 c) Individuals usually are not equipped to complete the intense RCA process on their own.
d) Teams are better able to stand up to the conflict that usually comes about when the results of the RCA are made public.

a) Understanding what led to an error requires diverse perspectives.

Health care is complex. Discovering why an error took place requires multiple perspectives from people in different professions. Working in a team may upon occasion slow the process down, but it will improve the quality of the outcome.

a) Doing a complete and thorough reconstruction of what happened before the event.
b) Defining what should have happened for the patient.
c) Identifying what caused the event.
d) Creating a fishbone diagram.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis.

 a) Team factors, institutional context, and organizational factors
 b) Budget, human nature, and organizational factors
c) Team factors, human nature, and PDSA cycles
 d) Psychology, PDSA cycles, and management factors

Correct Answer:a) Team factors, institutional context, and organizational factors

In his papers on this topic, Charles Vincent lists seven categories of factors that influence medical practice and error. These include patient characteristics, task factors, individual staff member characteristics, team factors, work environment, organizational and management factors, and institutional context.

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis.

 a) Prathibha hid her diagnosis of asthma, so the team was not aware of her respiratory risks.
b) The nurse responsible for Prathibha was unqualified to monitor complex medical patients.
c) Respiratory compromise can occur in patients with underlying conditions post-operatively. It is unlikely that this outcome could have been prevented.
 d) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome.

Correct Answer:d) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome.

RCAs are about identifying systems-based issues that contributed to an error, so that these issues can be corrected. Blame, such as in A and B, is not part of RCAs. Answer C is also incorrect, as there are almost always other factors that contributed to the error.

·         Be clearly linked to identified root causes

·         Address all of the root causes

·         Be designed to reduce the likelihood of recurrence or severity of the outcome

·         Be clear and concise and kept to a minimum

·         Be prioritized wherever possible

Be SMART: Specific, Measurable, Achievable, Realistic and Timed

The list of actions an RCA team suggests depends on the case at hand. But the recommendations often fall into one of these categories:

·         Standardizing equipment

·         Ensuring redundancy, such as using double checks or backup systems

·         Using forcing functions that physically prevent users from making common mistakes

·         Changing the physical plant

·         Updating or improving software

·         Using cognitive aids, such as checklists, labels, or mnemonic devices

·         Simplifying a process

·         Educating staff

·         Developing new policies

A strong action

·         is likely to eliminate or greatly reduce the likelihood of an event. It uses physical plant or systemic fixes with application of human factors principles.

intermediate action

·         is likely to control the root cause or vulnerability. It employs human factors principles, but it also relies upon individual action such as a checklist or cognitive aid.

by itself is less likely to be effective. It relies on policies, procedures, and individual action

  strong, intermediate, or weak?

strong

This simplifies the process and thus makes it less prone to error

weak

Training, while beneficial, only impacts staff members who participate. People can also forget their training and revert back to old ways of doing things, so as a recommended action, this may be a bit weak.

add more nurses to the unit

strong, intermediate or weak?

intermediate

. A decreased workload may decrease errors because staff members are not rushing around as much. However, adding more people doesn’t automatically lead to safer care.

add a checklist for a surgical procedure

strong, intermediate, or weak

intermediate

Checklists are only effective if they are used – and if the items on the checklist really have a strong connection to patient safety.

write a new policy about hosptial transport

strong, intermediate, or weak?

weak

Policies don’t usually change behavior on their own and can be difficult to enforce

strong

Standardization of equipment is a powerful way to reduce the likelihood of errors.

strong, intermediate or weak?

strong

Changing the physical environment in which people work has a longer-lasting impact than giving instructions to one group of staff members

Step 6: write a summary and share it:

All of the work of an RCA is for nothing unless it is communicated to others in a way that is understandable. This can be an opportunity to engage the key players to help drive the next steps in improvement.

When communicating about the RCA, a final report or presentation to administrators and stakeholders is the minimum. A presentation (or report) should include a clear description of what happened, the root causes and contributing factors to the event, and recommendations for how to prevent the error from occurring again – mirroring the goals of the RCA itself. It should also describe who was on the RCA team and what methods they used to gather and interpret information.

Some of the people who should receive the report include organization leadership, the heads of the departments involved in the event, and members of the risk management and quality improvement departments. Teams should also share the report with the people involved in the incident and with the patient and his or her family. This underscores that the RCA is about improving patient care and not about placing blame. If written in a blame-free tone, the RCA report helps those who were involved in an error move from feelings of pain and guilt to action and prevention. For patients, knowing that some good has come from their misfortune – that other patients will be less likely to have the same thing happen to them – can be a powerful factor in their healing after an event

RCA’s can make industry safer across the board ex-if shared with other hospitals

1. people conducting RCA may not know exactly how to conduct one, therefore, changes that get to the root of the error may not happen

2. doesn't hold indiv accountable enough-by taking a systems approach, individual negligance may be overlooked

) Which of the following is the best recommended action statement?

a) Assign more staff to the job of calling patients with their INR results.
b) Post signs reminding the staff to call patients with their INR results.
 c) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up.
d) Create a policy that specifies that patients with INRs must be called with their results within one week.

a) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included.
b) A clear description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included.
c) A general description of what happened, root causes, and recommendations for prevention. Team members and methods should be included.
d) A general description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included.

a) All providers in the hospital and the public relations office
b) The public relations office
c) Practice leadership and the hospital leadership
d) Hospital leadership and the public relations office

c) Practice leadership and the hospital leadership

When communicating about the RCA, a final report or presentation to administrators and stakeholders is the minimum. Some of the individuals who should receive the report include organization leadership, department heads of those departments involved in the event, and members of the risk management and quality improvement departments. Teams may also share the report with the individuals involved in the incident, as well as the patient and his or her family. This underscores the fact that the RCA process is about improving patient care and not placing blame. If written in a blame-free tone, the RCA report helps those who were involved in an error move from possible guilt to action and prevention.

a) They are often conducted by those unfamiliar with the local context of the error and do not always produce actionable recommendations.
 b) People participating in the RCA may not be familiar with how to conduct them, and the costs of implementing the actions may be too high.
c) They are often conducted by those unfamiliar with the local context of the error, and the costs of implementing the actions may be too high.
 d) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations.

a) The medical resident caring for her did not know the appropriate antibiotics for this type of infection.

One concern with RCAs is that by focusing upon systems, those reviewing errors may overlook issues that point to individual issues, such as deficits in knowledge. Answers B, C, and D describe clear system issues that would likely be uncovered through the RCA process.

(week 9 reading)

Medication administration errors by nurses: adherence to guidelines

article

Nurses were watched based on 5 rights and med error preventative guidelines

near misses occur more frequently than harmful errors therefore can be better in reducing errors

Med admin errors common, Nurses often gave drugs that they did not prepare themselves and rarely washed their hands before giving oral or external medications. Other types of errors such as wrong patient and wrong dose errors were much less frequent, but may have more potential for harm. These data suggest that both implementation of educational strategies, and tracking of performance will be helpful. In the longer term, technological solutions such as bar coding and implementation of electronic medication administration records may also be helpful

Nurse administering drug was same as documenting was highest compliance

Nurses washing hands before oral meds lowest compliance

(PS 105)

Dr. John Banja, PhD, of Emory University and others report that we have a number of reasons for not communicating when something bad happens (8 reasons)

1.       A psychologically reactive need to preserve a sense of self
2. Fear of admitting responsibility for making an error that may have hurt someone
3. Fear of anger from the patient and/or someone in authority
4. Fear of loss of job or position
5. Threat of censure
6. Threat of medical malpractice claims
7. Fear of colleague disapproval
8. Fear of negative publicity

the discussion of clinically significant facts between providers and/or other … personnel and patients or their representatives about the occurrence of an adverse event that could reasonably be anticipated to result in harm in the foreseeable future.  however, that the term can connote the release of privileged information or suggest that there is a choice about imparting the information to others. Further, many people associate the word “disclosure” with legal agreements.

prompt, compassionate, and honest communication with family and patient following an incident is essential

conveys a sense of openness disclosure does not

implies a continual dialogue

an injury that was caused by medical management rather than the patient’s underlying disease; also sometimes called `harm,’ `injury,’ or `complication.

open communication is also what’s most likely to benefit the patient and the caregiver.

Trust is a key part of caring and healing, and communicating openly is essential for maintaining trust.

open communication may be the best thing for you and your organization both morally and financially

It’s commonly assumed that communicating with patients after adverse events increases the risk of malpractice claims and lawsuits. However, many hospital risk managers are starting to view open communication as a way not only to be patient-centered but to reduce malpractice claims.

however, this does not eliminate the risk of a lawsuit

in the event a client is sued, it can provide insight to the jury that you were open and honest

1. Concern about standards of care – both patients and relatives wanted to prevent similar incidents in the future
2. The need for an explanation – plaintiffs wanted to know how the injury happened and why
3. Compensation for actual losses, pain, and suffering or to provide care in the future for an injured person
4. Accountability – plaintiffs believed that the staff or organization should be accountable for their actions

a) The medical explanation is too complex for most patients to understand.
b) Most patients don’t want to be told when these types of errors occur.
c) You’ve caused harm when the goal of your job is to help people.
d) Patients are much more likely to file lawsuits when they’re informed openly about these types of events.

Correct Answer:c) You’ve caused harm when the goal of your job is to help people.

The difficulty of admitting that you have harmed a patient whom you were supposed to help can be one of the greatest challenges in communicating with patients about adverse events. However, overcoming this challenge — and explaining what happened in a simple, forthright manner to the patient — is important. Not only do most patients want to know the truth, the health care industry is appreciating more and more that open communication can actually help prevent lawsuits when errors occur.

) Why is it important to communicate with the patient about this event?

Correct Answer:d) A and B

Open communication about all outcomes of care, including adverse events, is essential to establish and maintain patient-provider trust, and is viewed as a fundamental ethical requirement by many professional organizations, including the American Medical Association, the American College of Physicians, and others. Although open communication may decrease the risk of lawsuits, it does not eliminate all risk.

a) “Communication” implies verbal communication, whereas “disclosure” implies written communication.
b) “Communication” refers to information given to patients that cannot be used in court, whereas “disclosed” information can be used in court.
 c) “Communication” implies a continual dialogue, whereas “disclosure” implies a one-time transmittal of information.
 d) A and B

c) “Communication” implies a continual dialogue, whereas “disclosure” implies a one-time transmittal of information.

In a 2006 position paper developed by the Harvard Medical School Affiliated Hospitals, the authors use the word “communication” — as opposed to “disclosure” — because it conveys a sense of openness and reciprocity, and implies a continual dialogue. Furthermore, the term “disclosure” can connote the release of privileged information or suggest that there is a choice about imparting the information to others, and many people associate the word “disclosure” with legal agreements.

a) Information openly communicated to patients about adverse events in their care cannot be used in court.
 b) Open communication with patients can assuage caregivers’ feelings of guilt.
c) Due to its complexity, communication with patients following adverse events is best done by lawyers.
 d) All of the above

Correct Answer:b) Open communication with patients can assuage caregivers’ feelings of guilt.

Communicating about adverse events to patients and families can assuage the feelings of guilt that commonly arise among health care providers. Training in communication is helpful, but communicating after an adverse event is not unduly complex, and it should be done by those directly involved in the incident. The information communicated may be used in court, although laws may vary on this subject from state to state and country to country.

a) They feel the harm is not their fault.
b) They lack empathy for patients and families.
c) They fear disapproval.
d) All of the above

Correct Answer:c) They fear disapproval.

In the paper discussed in this lesson, published by Banja and colleagues, there were many reasons why providers found it challenging to communicate with patients and families after adverse events, many of which related to fear — fear of disapproval, fear of job loss, fear of anger from the patient, fear of lawsuits, etc. Providers did not discuss lacking empathy for patients and families or feeling that the harm was not their fault.

·  Step 1: Care for the patient. The first priority is to address the current health care needs of the patient by assessing the patient’s condition and determining what, if anything, needs to be done immediately

·  Step 2: Communicate with the patient. After caring for the patient’s immediate clinical needs, start preparing for the initial communication session with the patient and/or the patient’s representative.

“I am so sorry that this happened to you,” even if the cause is not yet known. Finally, it should include a promise to follow up and maintain clear, ongoing communication with the patient and family.

·  Step 3. Report to appropriate parties

Step 4. Check the medical record. The medical record should contain a complete, accurate record of the clinical information pertaining to the unanticipated adverse outcome.

§  Objective details of the situation, written in neutral, nonjudgmental language 

§  The patient's condition immediately prior to the event

§  The intervention after the adverse event and the patient response 

§  Notification of the primary care physician and attending physician

§  Information shared with the patient and/or patient’s representative following the event

If the equipment is not left as it is for detailed analysis, you run the risk of altering or destroying important information that could be critical to understanding the event and preventing similar ones.

: keep it simple, express empathy and compassion, and don’t place blame.

In your initial communication, speak clearly, slowly, and directly. Pause often to allow the listeners to collect their thoughts. If the news is very bad, the patient and the family are not really likely to hear much of it.

If you picked A – the physician caring for the patient – you are correct. It would be quite reasonable, however, for a pair of caregivers (such as a nurse and a physician) to speak with the patient. Since the patient is likely to have questions for the nurse, it could be quite helpful for the nurse to have participated in the initial communication.

Although, the physician is the best because they can determine future treatment plans

(PS 105)

When an error occurs, which of the following is generally the proper order of prioritization?

c) Care for the patient, communicate with the patient, report to all appropriate parties, check the medical record

 a) A risk manager
b) The patient’s physician
 c) The patient’s family
d) All of the above

d) All of the above

The physician who is responsible for the patient’s care is usually the best person to have an initial conversation after an error; however, he or she doesn’t have to be alone. For instance, the physician may want a risk manager to accompany him or her — risk managers are skilled communicators trained in conflict resolution and “delivering bad news.” It may also be helpful to have yet another person in the room, such as a case manager or relative, to provide psychological support to the patient and help the patient process and maintain information.

If you are responsible for the initial communication with the patient about the error, which of the following should you be sure to do?

Correct Answer:a) Speak clearly and directly

It is important to acknowledge that the event occurred by speaking clearly and directly. You probably don’t know exactly what caused the error at the time of the initial communication, but that’s OK. Rather than completely disguising your feelings, you should express empathy and compassion.

a) Your intention to prevent this type of error from happening again
 b) The punitive action that will be taken against the person at fault
 c) Why this error is not anyone’s fault
d) A and B

Correct Answer:a) Your intention to prevent this type of error from happening again

After an error, patients and families want to know what will be done to make the same type of error less likely to occur in the future; even if you don’t have all the answers yet, it’s important to reassure them that preventing this type of error is your goal. Until it is clear how the mistake happened, it is not appropriate to discuss punitive action or explain what or who may have been at fault.

a) Her response to the error
b) What was done/is being done to address the error
 c) Notification of the patient’s providers
d) All of the above

PS 105-

fundamental attribution error

The fundamental attribution error is related to how we explain other people's behavior. When a caregiver accidentally harms a patient, we tend to attribute such behavior to one of two possible causes. We may decide that the caregiver’s behavior was a result of personality – something inside her, such as her attitude (“she’s arrogant”), a motive we ascribe to her (“she wanted to get out of work as soon as possible”), or an enduring trait (“she’s always in a hurry”). Or we may decide that the behavior was a result of something outside the caregiver, that is, the external situation in which she found herself (“the unit was so unbelievably busy, who could help but hurry?”).

a) She should speak calmly with you about what happened and how you’re feeling about it.
 b) She should remind you that these errors happen to everyone and they’re no big deal.
c) She should encourage you to stay busy at work, to help you move past the incident.
d) She should suspend you immediately, so that you have a couple of weeks to process what happened and learn from your mistake.

Correct Answer:a) She should speak calmly with you about what happened and how you’re feeling about it.

Ideally, supervisors are trained to spot issues when they arise and to talk calmly with practitioners about what happened. Depending on the circumstances, the caregiver may need to take a break, go home, or take some time off — but there is no reason in this case to think you should be involuntarily suspended.

Your Answer:b) Offering support helps prevent depression or decreased job satisfaction.

a) “Someone almost died because things were so busy yesterday.”
 b) “The HUC almost killed someone yesterday because she doesn’t pay enough attention.”
 c) “The electronic health record can’t come soon enough — the current system almost killed someone yesterday.”
d) “I can’t believe what an awful situation the HUC ended up in yesterday; someone almost died.”

Correct Answer:b) “The HUC almost killed someone yesterday because she doesn’t pay enough attention.”

Three of these statements attribute the error to external factors; however, saying “The HUC almost killed someone yesterday because she doesn’t pay enough attention,” assumes the error occurred as a result of your internal makeup (i.e., you don’t pay enough attention), and is likely a fundamental attribution error. According to the theory of fundamental attribution error, our human tendency is to assume, wrongly, that people’s behavior is a reflection of their personal qualities rather than of the situation in which they find themselves.

a) Care coordination
 b) The Employee Assistance Program
 c) Ombudsmen
 d) The patient relations departmen

1. Acknowledgment: The first part of any apology is the acknowledgment of the event, which includes the identity of the participant(s), appropriate details of the event, and validation that the behavior was unacceptable.

2. Explanation: The second part of an apology is the explanation for committing the event. Explanations may mitigate the event (“I was late because of a medical emergency”) or aggravate the event (“I left the operating room to go to the bank”). Sometimes saying, “There is just no excuse for what happened,” can be the most honest and dignified explanation. Through this explanation, the speaker must accept responsibility for the event and make it very clear that the patient did not do anything wrong.

3. Expression of remorse, shame, and humility: This is the third part of an apology. In this context, remorse is a deep sense of regret. Shame is the emotion associated with failing to live up to one’s standards. Humility is the state of being humble, not arrogant. Lack of remorse, shamelessness, denial, and arrogance will undo most apologies.

4. Reparation: The fourth part of an apology is reparation, which can range from an early scheduling of the next appointment to canceling the bill to a financial settlement.

Not necessarily all four parts described here are present in every effective apology, but when an apology is ineffective, you can invariably locate the defect in one or more of these four parts

1. Restoration of self-respect and dignity
2. Feeling cared for
3. Restoration of power
4. Suffering in the offender
5. Validation that the offense occurred
6. Designation of fault
7. Assurance of shared values
8. Entering into a dialogue
9. Reparations
10. A promise for the future

When applied to the caregiver-patient relationship, an apology as defined by Lazare helps restore the patient’s dignity by acknowledging that she is important and warrants the caregiver's attention. The apology should include an assurance that the patient will not be abandoned and will continue to receive care (mechanisms 1 and 2). For example, the caregiver and the organization can positively communicate that they are committed to the patient's care by saying something like: “Please know that nothing has happened that will stop us from continuing to take the best care of you that we possibly can.

 a) Your institution will perceive it as risky.
 b) Your institution will encourage you to do it.
 c) You should not apologize until you discuss it with the risk management department.
 d) None of the above

c) Apologizing effectively and appropriately is more of an art than a science.

The correct answer is that apologizing effectively and appropriately is more of an art than a science; at the same time, it is something that you can learn and practice. Some institutions may see apologizing as a risky endeavor, because it may be construed as an admission of guilt and have legal ramifications (despite mounting evidence to the contrary). In these cases, clinicians should discuss apologizing to the patient with the risk management department, and use their best judgment about how to proceed. It is not true that you should only apologize in the event of a serious injury.

Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, “Why won’t someone help me?”

 a) Apologize profusely for the delay.
b) Explain that the resident didn’t give a clear medication order.
c) Give an overview of the science of pain management.
 d) Assess the pain and provide the medication.

Correct Answer:a) Assess the pain and provide the medication.

The first and most important issue when a patient receives less than ideal care is to make sure that the patient is stable and cared for. Only after the patient’s safety and comfort is addressed should the issue of an apology be considered.

a) A genuine apology could help Mrs. Bernardo recover from her trauma.
b) A genuine apology could help Nurse Janice feel better.
c) An apology is not recommended in this case.
d) A and B

“Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. In the future, someone will check up on you more frequently overnight. Again, I just want you to know how sorry I am that this happened.”

 a) Acknowledgment
b) Explanation
 c) Expression of remorse or shame
 d) Reparation

) When giving an explanation for why an event happened, it is always important to:

• It is probably not necessary to communicate with a patient about a near miss that does not cause harm.

   When an adverse event causes harm, or when a significant intervention is required to prevent harm, there must be communication with the patient and/or the family

  If the senior members of the care team feel that it’s not in the patient’s best interest to know about an adverse event immediately, then it may make sense to defer the communication or to communicate initially with just the family or a proxy representing the patient.

All events will vary in patient, family, and clinican response

The patient received magnesium incorrectly, but only became mildly sleepy. After a conversation between the nurse and obstetrician, the patient is given a small dose of calcium and the condition is reversed. Although the patient has been exposed to both magnesium and calcium unnecessarily, she does not know that this has occurred.

 a) Since there was no harm, and the patient is in the middle of laboring to deliver her baby, there is no reason to tell the patient or family.
b) The physician should tell the patient and family that the patient had an unusual reaction during labor that required treatment and she is fine now.
 c) The physician should tell the patient and family that the nurse made a mistake and will be reprimanded.
d) The physician, with the nurse in the room, should tell the patient that she received magnesium by mistake, a reversal agent was administered, and she and her baby should be fine.
e) The physician, without the nurse in the room, should tell the patient that she received magnesium by mistake, a reversal agent was administered, and she and her baby should be fine.
 f) The nurse, with the physician in the room, should tell the patient that she made an error in giving magnesium rather than saline, the mistake was quickly caught and reversed with calcium – which should not have a detrimental effect on the baby – and she can continue to care for the patient or be replaced, at the patient’s discretion.
g) The nurse, without the physician in the room, should tell the patient that she made an error in giving magnesium rather than saline, the mistake was quickly caught and reversed with calcium – which should not have a detrimental effect on the baby – and she can continue caring for the patient or be replaced, at the patient’s discretion.
 h) The nurse should be removed from care of the patient, and the physician should tell the patient that the nurse made an error in giving magnesium rather than saline and the mistake was quickly caught and reversed with calcium – which should not have a detrimental effect on the patient's baby.

You’re beginning a skin biopsy of a suspicious mole on a patient. As you insert a needle into the skin on the patient’s nose, you realize that you accidentally drew up lidocaine (an anesthetic) that contains epinephrine (a vessel constrictor), rather than plain lidocaine. The current belief is that lidocaine with epinephrine can cause vasoconstriction, leading to cell death and skin sloughing. You remove the needle without injecting any of the lidocaine with epinephrine.

 a) You should not tell the patient about the event.
 b) You should tell the patient only if she asks what happened.
 c) You should tell the patient only if she experiences long-term effects.
d) You should tell the patient about the event regardless of whether she has long-term effects or whether she asks.

Correct Answer:d) You should tell the patient about the event regardless of whether she has long-term effects or whether she asks.

To tell the truth and maintain trust, you should inform the patient about what happened. At this point, you’ve stuck a needle in the patient’s skin unnecessarily and will need to stick another needle in shortly ? this one containing the correct drug. The first stick constitutes harm to the patient, and it warrants an explanation, even if the harm is highly unlikely to be permanent.

a) Patients almost always want to know about near misses of this kind.
 b) You should tell the patient what just happened because it’s required by most organizations and the right thing to do.
 c) It is probably unnecessary to tell the patient about this event.
d) A and B

Your Answer:c) It is probably unnecessary to tell the patient about this event.

Correct Answer:c) It is probably unnecessary to tell the patient about this event.

There is general agreement among patients and caregivers that it’s not necessary to communicate about near misses. In this case, you realized your error and corrected it well before it could cause harm, so the patient probably doesn’t need to know about it. Think about it this way: Many of us fly from one destination to the next unaware of the events in the cockpit. How would you feel if the pilot used the intercom to share every near miss that occurred?

 a) Given the severity of the error, you need to disclose the error immediately regardless of the patient’s condition.
 b) Given the fact that there will not be any long-term consequences to the patient, you should not discuss the event with him at any point.
c) Given the fact that most patients prefer not to know about these types of errors, you should only disclose the error in the event that he specifically asks the reason for his extended stay.
d) Given the sedation, it might be reasonable to wait until the patient is more alert and then disclose the error.

Correct Answer:d) Given the sedation, it might be reasonable to wait until the patient is more alert and then disclose the error.

Although in general it is best to communicate with the patient as soon as possible after an event, waiting until sedation has worn off is probably reasonable. However, at some point you will need to disclose this error ? studies show patients are aware when errors occur and want to know the truth about them.

 a) When an adverse event causes harm, there should be communication about the event with the patient and/or family.
 b) When a near miss occurs, there should be communication about the event with the patient and or/family.
c) When an adverse event causes harm, the patient must be notified immediately.
d) All of the above

Correct Answer:a) When an adverse event causes harm, there should be communication about the event with the patient and/or family.

Only the first statement is always true: When an adverse event causes harm, there should be communication with the patient and/or the family. Although that communication should usually occur promptly, in some cases it may be in the patient’s best interest to briefly defer communication of the adverse event. It is often not necessary to communicate with a patient about a near miss that does not cause harm.

automatic thinking; it’s rapid and effortless. It’s like riding a bike, using a computer, or driving a car if those are things you do often.

This is an example of how errors of execution occur

equipment design can cause this

freq lead to mistakes

(i.e., errors of planning) such as improper testing, unnecessary treatments, and missed diagnoses.

Some examples of these CDRs are memory bias; overconfidence; and confirmation bias, or the tendency to accept evidence that suggests you are correct and reject evidence that suggests you are wrong.

However, knowing and being able to properly classify every type of cognitive error is far less important than being aware that cognitive biases and heuristics exist. Once you understand that basic human brain functions naturally cause people to make errors, you can get over any notion that hard work and vigilance are effective safety systems.

factors related to the individual (as opposed to their environment). They include both psychological states and physiological states that cloud our judgment and thought processes, such as:

• Limited memory capacity
• Fatigue
• Stress, hunger, and illness
• Language limitations
• Hazardous attitudes

factors related to the situation the individual is in. They include environmental factors such as:

• Noise, heat, and light
• Long work schedules
• Inadequate training
• Poorly designed rules or procedures
• Interruptions and distractions
• Language barriers

one of the most common physiologic factors that can lead to error in both automatic and controlled thinking

can be a symptom of other problems, such as poor sleep patterns, stress, anxiety, hypoxia, dehydration, and other medical conditions. Fatigue can also contribute to these interrelated problems.

After one night of missed sleep, cognitive performance may decrease 25 percent. After a second night of missed sleep, cognitive performance can decrease 40 percent.² Ways that fatigue can impact an individual’s performance and personality include:

• Reducing decision-making ability
• Prolonging response time
• Increasing lapses in attention
• Negatively affecting short-term memory
• Lessening ability to multitask
• Increasing irritability, moodiness, and depression
• Decreasing ability to communicate

Boredom coupled with fatigue can lead to sleepiness, which can also affect performance. Scientists have studied fatigue as a contributing factor to errors in many high-risk industrie

In 2008, two pilots on a regional flight fell asleep at the same time and flew the plane 30 miles past its destination in Hawaii into open ocean. Air traffic controllers tried to contact them nearly a dozen times during 17 minutes. An investigation found that one pilot’s sleep apnea, which caused him to lose sleep at night and feel fatigue during the day, as well as long work hours, contributed to the incident.

In this scenario, an illness and fatigue (and possibly boredom) were internal factors that contributed to the error. Can you identify the external factor that contributed to the error in this scenario?

(a) Factors that are in play before action takes place (i.e., predisposing mental and physiological states, such as fatigue, stress, dehydration, hunger, and boredom)

(b) Factors that directly enable decision-making, such as perception, attention, memory, reasoning, and judgment

(c) Factors that directly enable decision execution, such as communication and being able to carry out the intended action

That’s why vigilance and hard work can be effective to a point, but in the long run, we cannot sustain performance by merely trying hard and paying attention

• When patients receive an incorrect medication or treatment because of look-alike medication names and packaging
• When health care staff incorrectly identify a patient because he or she has the same or a similar-sounding or -looking name as someone else
• When a nurse ignores a critical alarm because there are so many false alarms on a unit that the nurses working on the unit have become desensitized
• When a resident is called in the middle of the night to care for a patient and does not remember the next morning having been contacted or the orders she gave

a) Interactions among humans
 b) Interactions between humans and machines
 c) Interactions between humans and the environment
d) All of the above

a) Optical illusions
 b) Skipping a step on a checklist to save time
c) Mistaking one drug for another because of look-alike packages
 d) A and C

Optical illusions and mistakes involving look-alike drugs and names reflect unconscious processing by the human brain. Unconscious processing is a fundamental part of human cognition that can lead to human error even when people are trying their best. Safe systems take these known characteristics of human cognition into account to help people do things the right way.

a) If you understand the factors that cause people to make mistakes, you can hire safer providers.
 b) If you understand human factors principles, you can ensure your system is perfectly safe.
 c) If you understand the factors that affect human performance on critical tasks, you can design a safer system.
 d) If you understand human factors principles, you can always justify using the latest technology at the bedside.

a) The nurse’s training was out-of-date.
 b) The nurse was prone to error because she was tired.
 c) The nurse had become complacent and stopped trying hard.
 d) The nurse deliberately ignored protocol.

b) The nurse was prone to error because she was tired.

• Simplify
• Standardize
• Use forcing functions and constraints
• Use redundancies
• Avoid reliance on memory
• Take advantage of habits and patterns
• Promote effective team functioning
• Automate carefully

taking steps out of a process

When a process is complicated, people performing that process will need to spend a lot of time learning how to do it effectively. Even if they “master” the process, if it is complicated, there are more opportunities for users to leave out critical steps in the process, get confused, and give up.

Simplifying sometimes involves clarifying the meaning of something or ensuring that an item’s purpose is easily understood by the user. Look at these two medications before the manufacturing company redesigned the packaging

This eliminates variation and confusion and promotes predictability and consistency. When interacting with a standardized process, you know exactly what will happen, when, where, how, and by whom. Standardization results in a uniform and common way of completing a task. A well-designed standardized process should reduce complexity and variation.

ex-getting the same whopper from any burger king

make it impossible to do a task incorrectly. They create a hard stop that you cannot pass unless you change your actions.

ex-manufacturers redesigned enteral tubing (tubing intended for oral administration) so that it could not be connected to intravenous tubing. This simple change minimized the opportunity for a mix-up.

A typical redundancy is a double check, when one person checks the work of another. This is very common in health care and in some cases a requirement. To be effective, the double check must be independent and follow a set of steps.

needed when When a secondary system is needed in the event a first system fails and
Within a situation where a failure in the first step can result in serious harm

can also use technology over social redundancies

Despite its potential usefulness, a double check can also present an opportunity for error. Two people can be prone to make the same mistake for the following reasons:

• The second person may not be as attentive to the checking as he or she should be.
• The second person can be influenced by the first person to see what he or she would expect.
• Double checks can be overused, making people less likely to take them seriously.

hen engaging in a complex process — such as administering medication — it can be helpful to use a list.

Checklists are used in many industries in which forgetting something or making a mistake can have serious consequences

The goal of a checklist is not to complete the checklist, but to use it as a guide to completing the tasks on the checklist.

Habits are those actions we perform in consistent circumstances and are triggered by our surroundings. A pattern is a recognizable regularity in events.

ex-putting a medication list with an insurance card so you have it for a doctors visit

Technology provides many advantages when used to mitigate the effects of factors contributing to error. We can use technology as a reminder system, a reliable way to ensure that a task is completed as designed, a screen for errors, and so forth

Human beings must still be very present when interacting with technology to ensure its proper and effective use.

Which of the following is a basic strategy for minimizing the opportunity for error in a process?

 a) They are needlessly inefficient.
b) They remove the opportunity for error.
c) They require two people to do the work of one.
d) None of the above

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient’s vital signs, you could simply look at the sheet of paper clipped onto the end of the bed.

 a) It needs to be simplified.
 b) It needs to be standardized.
c) It needs redundancies added.
 d) It needs to avoid reliance on memory.

 a) Using forcing functions and constraints
 b) Automating carefully
c) Simplifying
d) Avoiding reliance on memory

a) A forcing function
 b) Simplification
 c) Redundancy
 d) A and B

technology can be inadvertently designed to set people up for mistakes

alarm fatigue

• Poorly designed interfaces can cause clinicians to click the wrong option because it’s close to the right one — a so-called juxtaposition error.
• Systems designed with relevant information on different screens can make it harder for physicians to see the big picture.
• Automation complacency causes people to lose skills or stop paying attention when processes don’t require their input.
• People place too much trust in technology and become overly reliant on it. For example, in the case of Pablo Garcia, a nurse noticed the unusually large dose, but trusted the computer system that it was correct.

organizations should redesign their processes to be effective and use technology to simplify and standardize those processes.

A first step in using technology to improve safety is to determine whether technology will actually help make a process safer. If it won’t, don’t use it.

Which of the following statements about bar-cording systems is true?

Effective ways for addressing defects in the human-technology interface include:

You’re working in an outpatient clinic that recently started using an electronic health record (EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones’s urinary tract infection. As you enter the order, a warning screen pops up saying that she has chronic kidney disease, and the medication dose should be adjusted based upon her last recorded creatinine level (a measure of kidney function). However, you know that Mrs. Jones’s most recent creatinine level — recorded at a different clinic and therefore not available in your EHR — came back normal. When you attempt to move past the warning, the system will not allow you to proceed.

 a) How technology can be used to make patient care safer
b) How technology can be used to make care more efficient
c) How technology that dictates your work — rather than facilitates it — can introduce unintended problems
d) A and B

a) The pump is dictating rather than facilitating your work.
 b) The pump could malfunction.
 c) There is no risk associated with the pump.
 d) A and B

a) Switching to an electronic health record (EHR) platform that is of comparable quality but lower cost
 b) Implementing redundancies, in which providers double-check each other’s electronic inputs
c) Providing inpatients with electronic tablets so that they can keep in better touch with the outside world
d) Giving nursing assistants electronic tablets to ensure there’s no delay in recording patients’ vital signs

(week 5 reading)

Lateral violence

a deliberate and harmful behavior demonstrated in the workplace by one employee to another,is a significant problem in the nursing profession.  Problems in work enviro and delivering px care, happens to an employee of equal or lesser position

Usually these acts are subtle and build over time rather than one single devastating act

Nurses primary profession for being victim of lateral violence or witnessing it

Overlooked and unreported due to being falsely accepted as being okay

Victims report an overall decreased sense of well-being, physical health complaints, and depressive symptoms-leads to ineffective coping-can lead to more psych disorders-higher risk of physical ailments such as CV disease

Nurses more likely to leave org and therefore can cause increased costs in replacing them

Marion Conti-O’Hare believed that individuals are often led to specific professions, such as nursing, by their desire to relieve the suffering of others after experiencing or witnessing traumatic events in their own lives.

Indiv have effective or ineffective coping mechanisms.  Ineffective coping mechs-impact of trauma remains unresolved and pain remains, “walking wounded”, these indiv have problems empathizing and have problems with stuff

Effective-pain can be resolved and nurse can work as “wounded healer”

recognition

transformation

transcendence

***Upon completion of this three-step process, the walking wounded becomes the wounded healer with an increased ability to understand others’ suffering and empathize with their pain

Can repeat this process if needed

(week 5 reading)

recognition

Recognition-Awareness that something is affecting a person in a negative manner, either through his/her own thought processes and self-evaluation, or with the assistance of other people in his/her life.

• What happened?
• What could be changed?
• How should it have been handled?

(week 5 reading)

transformation

Transformation-Seeking affirmation and control over feelings of pain and/or fear through counseling and/or sharing; using energy from the past to increase understanding of the present and future

• What can be learned from the incident?
• Has this changed me or the people I care about?
• How can this be used to make things better?

Transcendence-A higher level of understanding (can be spiritual and/or higher thinking) that allows the person to use the understanding achieved to increase their therapeutic relationship with others, only happens if other two steps do,

• I understand your pain.
• How can I make things better for you?

Those who have experienced either physical or verbal trauma in their lives that they have not dealt with, allowing alterations in their ability to cope with current stressors, leading to negative results

Those who, through self-reflection and spiritual growth, achieve expanded consciousness, through which the trauma is processed, converted, and healed. The scar remains, giving the person a greater ability to understand others’ pain.

basic assumptions was that every individual has experienced some sort of trauma in life. Both conscious and unconscious factors, derived from personal experiences, drive human behavior and encompass all individuals. Instead of perceiving these factors as dichotomous, they must be recognized as co-existing.  The process of identifying this ‘duality’ and seeing both parts as a whole is called ‘transcendence. Leads to finding “wholeness” and reason of “it”

Rather than being “clean hands” healer, Jung believed all healthcare workers carried damage, He has developed his ‘counter-transference’ theory, in which he describes a wounded healer’s complete response, both conscious and unconscious, to a patient. Jung believed that the use of countertransference by a sufficiently recovered wounded healer would be beneficial to for the patient when it was used to facilitate empathetic connections and constructively inform the healing process.

wounded healer can use past experiences to better assist those who are dealing with the same type of problem, however, if negative parts of the provider are not resolved, there can be damage for the patient and the provider

1. In the search for ‘wholeness,’ traumatized individuals may pass from the stage of walking wounded to wounded healer.
2. Nurses and other health professionals become wounded healers after recognizing, transforming, and transcending the pain of trauma in their lives.
3. Wounded healers become able to use themselves therapeutically to help others.
4. This transformation will have a positive impact on the health care system, society, and the nursing profession as a whole

Nurses are more stressed than normal people

Early identification of inappropriate behaviors by nurse managers, and all leaders, is key to identifying and resolving lateral violence; recognize walking wounded and break the cycle

Refer to patient safety and EAP programs, need to have a culture above this,

Healthy Work Environments (HWEs) are important for the overall health of nurses, for successful nurse recruitment and retention, and for the quality and safety of patient care.

Charac by high level of trust between management and employees; by employees who treat each other in a respectful manner; by an organizational culture that supports skilled communication and collaboration; and by a climate in which employees feel emotionally and physically safe

Sees nurses on path to becoming skilled communicators, interact w/ enviro and people in enviro to create a co meaning between them, nurses responsible for consequences of pattern of communication, ethically mandated to become skilled communicators (part of ANA code of ethics)

Many nurse environments still unhealthy, need to focus on what they can do and not what others should do

Provide introspection and allow nurses to become skilled communicators

Parse’s five factor model for becoming a skilled communicator (week 5 reading)

1.      Authentic- Process of self-discovery by understanding one’s purpose; holding and practicing professional values; practicing with heart; establishing enduring relationships; and practicing self-discipline.

2.      Becoming reflective-Process of pondering, carefully and persistently, the meaning of an experience; creating meaning from past or current events that guide future behavior; self questioning so situations become more clear and coherent. Becoming reflective can be differentiated as reflection-in-action and reflection-on-action. Reflection-in-action means the nurse develops the ability during interpersonal actions to recognize a problem and to act to make the situation better. Conversely, reflection-on-action is being reflective after the encounter. The act of reflecting-on-action reviews an interaction after it has been completed to explore the reasons why those involved may have responded as they did

3.       Becoming aware of self-deception-Process of acknowledging a misconception that is favorable to the person who holds the misperception or failure to see that one has a problem, ex the emperors new clothes, misperceive ability to wing it and listen well,

4.      Mindful-Process of developing a heightened awareness of and alertness to verbal and nonverbal communication; developing present-centered awareness, and acknowledging and accepting each thought and feeling as it is.

5.      Candid-Process of purposefully speaking with frankness that is free from bias and risking speaking and hearing the truth.

No effort has been made in this article to address the role of managers in decreasing workplace conflicts. Rather, this article has focused on the importance of all nurses being willing to focus their attention on themselves, considering what they individually can and must do to effect HWEs. Nurses must recognize that a HWE, one in which they feel emotionally safe, begins with them.

Reasons Why physicians and advanced clinicians practice while sick article (week 5 reading)

·  Ninety-four percent of respondents believed that working while sick puts patients at risk.

·  Despite recognizing the risk, 446 respondents (83.1%) worked sick at least once in the past year, with 50 (9.3%) reporting having worked sick more than 5 times in the past year.

·  Primary reasons why respondents work sick included not wanting to let colleagues and patients down, extreme logistic challenges in finding coverage, a strong cultural norm to work through sickness, and ambiguity about what constitutes too sick to work.

The establishment of a healthy work environment requires strong nursing leadership at all levels of the organization, but especially at the point of care or unit level where most front line staff work and where patient care is delivered

helps to create a healthy work environment

Current leaders need to facilitate new leaders to help them grow

1.       Create the leader within yourself

2.       The science of managing the business

3.       Learn the art of leading people

(week 5 video)

How clinicians can incorporate innovation in our daily work:

Be observant to make things different and better, outliers and approaching problem differently, both extremely well and extremely poorly