Courses

Safe Medication Administration: Everything You Need to Know to Improve Your Practice – EXPIRED

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Click Here to Download the Course PDF

You can also access this content on YouTube:

Safe Medication Administration Video

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updated 7/18/2019

Safety First Blog

Have you been fired (or know someone who has)? Resources for bouncing back

Listen to the Interview on iTunes

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I have not failed. I’ve just found 10,000 ways that won’t work ~Thomas Edison

Starting out with a quick name change. After talking to my business coaches, family, friends and those of you who are following me, I have decided to change the name of the podcast to “Safety Rules”. Safety Rules is a more authentic reflection of my personality and it allows me to be a little bit silly, which I love. I want to ensure nurses have everything they need when safety challenges happen, and I have a gift for making difficult topics of conversation easier to swallow. I want to break the rules and open up conversations that we have been afraid of in the past, to provide learning experiences, so you can avoid the pitfalls I have fallen into. I am going to bring painful topics out into the open, and make you laugh. Enjoy!

This article is a follow up to episode #5, where I talk about getting fired and reported to the board of nursing. In that episode I described how it felt, and how I responded. In this episode I am going to give you everything I wish I had known about after I got fired. As I said in episode #5, I would really like for anyone else out there who has been fired, or “knows someone who has been fired” to benefit from my experience. There is a resource page for you on the website with all the info from this blog/podcast, so please head over to www. Safetyfirstnursing.com to check it out. You can sign up for the SFN newsletter to find out when there is a new article, post, podcast, video or continuing education activity. I started Safety First Nursing to support the psychological, physical and emotional safety of patients and nurses with education, resources and research. On the website you can find a comprehensive list of patient safety resources, as well as continuing education with a patient safety focus. If you sign up for the newsletter, you will also get the latest updates on Rose’s journey through nursing school. Rose is a young Haitian woman I met through my work with Consider Haiti. Safety First Nursing is sending Rose to nursing school – 10% of all purchases of continuing education will go to Consider Haiti to support this goal. However, I just went ahead and set the tuition, securingher a spot, and right now she is taking English lessons – a lot is happening.

I recently posted on Facebook and Instagram about a moment of weakness I was having. The SFN website finally went live, and people did not just spontaneously go there and buy my course. I was irrationally sad. I knew and continue to know how much work it takes to get a start-up company off the ground, but deep down, I was hoping that people would just magically find me. I also didn’t get a big scholarship I had applied for. I got a really nice letter though – it said that over 187 people had applied, and that my application was one of the best (does this form letter go to all 186 people who also didn’t get the scholarship, I am wondering?) and that I should apply again (I swear if I am not done with my doctorate by the end of this year, I may lose my mind. But of course I will apply again if I am STILL IN SCHOOL). And finally, a seminar I was supposed to teach didn’t sell and got cancelled. YEAH! I got a lot nice responses about not giving up. As Mary Pickford once said, “Failure isn’t falling down, it’s staying down” and I just want to share that aside from my mom and dad and my friends telling me I am awesome in various ways (which means a lot, by the way), I got some great quotes. There was also a nice mention of Einstein and all his failures…

so I am in good company. I know cheesy quotes don’t solve the problem, but do reach out, and do read one or two. You don’t have to admit they made you feel better. One last quote from Oprah, and then we will get started: “Think like a queen. A queen is not afraid to fail. Failure is another steppingstone to greatness.”

Type in “why failure is good” and you get link after link to articles about the benefits of failure. There are resources out there to help you get back up. Anyone who tries something new is going to fail at some point. There is so much information out there about failure, and what it can teach you. Some experts even advocate that failure (gulp) might be a good thing. Here is a brief list of the resources I would recommend you explore if you (or someone you know) is fired.

WHAT TO DO NEXT:

 

  1. Get inspired: I listened to two podcasts, one on quitting, and one on failure (link on the resources page for this article).   Listening to these podcasts really helped. I felt better. I felt like I was in good company, and it helped me understand why I tend to hang on to a bad situation, even when everything and everyone is telling me to quit before things get bad. Author Stephen Dubner says to fail early and often so you can quickly find out what you are (not) good at. Check. Watch Harry Potter author J. K. Rowling’s Commencement Speech on Failure. An inspiring quote:

“Failure meant a stripping away of the inessential. I stopped pretending to myself that I was anything other than what I was, and began to direct all my energy into finishing the only work that mattered to me. Had I really succeeded at anything else, I might never have found the determination to succeed in the one arena I believed I truly belonged.”

Watch the video Beyond Blame (1997), a 10-minute documentary about how medications errors affect everyone involved. Watch the Webinar from TMIT: A Hospital Accident: Lessons Learned (2011). This webinar was so powerful, I cried and got some healing. It is a story of taking responsibility and of forgiveness.

  1. Report your error on the ISMP website, and request support from them. Here is what they have to say about their services:

“Since its origin, ISMP has provided free, professional and emotional support to the second victims (as well as the third victims) of serious errors. Ongoing discussions at any time of the day, support and follow-up as needed, assistance with meeting requirements for presenting or attending educational programs and providing community service, and onsite support and/or testimony during licensing board hearings and criminal proceedings are just a few of the services we offer to second victims of errors. We can also provide these victims with a sense of community, rather than isolation, by putting them in contact with other second (and third) victims who have been through similar experiences.”

  1. Medically Induced Trauma Support Services (MITSS) also has a venue for getting support – go to their website and see what they have to offer. Here is their description of what they have to offer:

“MITSS is a nonprofit organization whose mission is to support healing and restore hope to patients, families, and clinicians impacted by adverse events. Their website provides an extensive set of Tools for Building a Clinician and Staff Support Program. Included in the toolkit are a quick 1-page assessment designed to give organizations a snapshot of where they stand regarding staff support in the wake of an error, and a comprehensive work plan for building a support system.”

  1. Communicate/Share: Post on Allnurses or Reddit and you will see many other healthcare providers have started conversations about being involved in error. Discussion topics include: How can a new RN who was fired from their first position due to two medication errors find another job, fired for medication error, life after a med error, what is the worst med error you or someone you know committed, I was suspended, Patient complaint – freaking out, How to support a coworker who has made a medication error and more. You can also post on the ProPublica Patient Safety Community, as well as Show Me Your Stethoscope – two Facebook groups that will provide support and perspective.
  1. Apply for unemployment. I would recommend doing this. I can’t guarantee you will get it. I applied, and the company that fired me said “nope” and then I appealed their nope, and then we had a phone interview which was me, a person from the Department of Employment Services, my used to be boss, and my used to be boss’s boss. If I hadn’t had the appeal, I would never have had access to my termination papers. In episode #5 I mentioned leaving my job without signing the termination papers and being told I could come in later in the week to sign. That is a lot of malarkey. Once I left the building, the response from the company was, “that information is our property” and basically, the only way to get at it was to get a lawyer. Be really careful when you search for the site for applying for unemployment – this is an area where you can easily be scammed. There is a link on the resources page to the North Carolina Division of Employment Security, which is part of the Department of Commerce – the website address should be a “.gov” – other sites may try to scam you, and will certainly waste your time.

The DES requests all paperwork from the company that you worked for and sends you a copy by certified mail (a great reason to apply if you don’t have a lawyer and you don’t have your termination papers). The appeals interview was gut churning. There is a procedure – you can’t talk until they tell you to talk, and you can’t ask questions until they tell you to ask questions, and if you do it wrong or out of order, they speak sharply to you. You get to listen to a re-telling of all the things they think you did wrong, and then you eventually get to say what you think you did right. It was horrible.

 

I heard from them within 24 hours –and I won. That felt pretty good. My husband told people I “won a wrongful termination case”…which is pretty funny – but the upside is I got some money for 13 weeks, long enough to keep us afloat while I waited to see if I got to keep my license. AND….drumrolllllll…..I did get to keep my license, with no disciplinary action, and they recommended I take a class on communication (yeah, tell me something I don’t know…agree agree, like, like).

What about looking for another job? Part of collecting unemployment is that you have to keep meticulous records of your job search. This is a good thing. I made a spreadsheet and put in the names, phone numbers, email addresses and notes from every contact I made. I am really glad I did that – and not just for the unemployment folks (who were really nice to me – I found the whole process to be simple and straightforward). The real issue is that I was so freaked out and depressed that I didn’t want to go back to work. I had a complete and total loss of confidence. I felt like a failure. I remember thinking maybe I should lose my license; maybe I was so worthless as a nurse that I shouldn’t be allowed to be one any more. Keeping records is a way to remember what you have done in the grip of emotional times – it’s not always easy to keep track of details when you are depressed and upset.

  1. Find another job: check out Donna Cardillo. She is a motivational speaker who has great resources for helping nurses find work after being involved in an error – there are links to her info on the resource page for this article. In her article, Picking up the Pieces of Your Career, her top recommendations include volunteering, networking and joining the state chapter of ANA for support. She has published a book called The Ultimate Career Guide for Nurses. In North Carolina there is NCWorks, which really helped me. I was required to meet with them for unemployment and I went into the meeting wondering what they could do to help – the answer is, A LOT. They have great counselors who will walk you through creating an online resume (it’s easy and it looks great).
  1. Explore legal action: I went so far as to get the names of a few, but never pursued it. NC is a right to work state, which means it is a right to fire state – which means your employer can fire you at any time, for any reason, unless it’s retaliation or discrimination (if you think either is the case, DO get a lawyer). Plus, for me to hire a lawyer would cost me time and money, and the company that fired me already has a bunch of lawyers, and time, and money, and no reason to give up, or settle. I talked to my husband about the idea of legal action – he asked me an important question, “what is your goal? Do you want your job back?” my goal? Well, I guess it would be nifty if the company that fired me said, “sorry, we were wrong, you are awesome and we never should have let you go…” but no, I didn’t want my job back. I don’t want to work for anyone who would treat someone the way they treated me. I had worked for them on and off for 10 years. That company had rehired me two different times. Maybe I wasn’t a model employee, but well…I had history…I cared, I said nice things about them, for goodness sakes.

I am adding an 11th hour addendum here – my friend Melissa, who has been an expert witness, told me about a lawyer, Lorie Brown who is also an RN! I am posting info about her on the resource page, but I have already contacted her – this is the kind of resource I would have really loved last fall. There is a place on her website that says, “Tell us your story”.

  1. Health Insurance. Let’s just say we have some now. I didn’t realize when they fired me that I still had another week of coverage (ASK). I cancelled a mammogram I could have had under the plan I had with my old employer. The COBRA quote I got for the remaining months of the year was actually reasonable, so I signed up, only to find out the day after open enrollment ended that the rate starting the following year would be 3x the initial quote. It took me a while to realize that the crappy way the COBRA folks treated me was a qualifying event for ACA. It was a painful month I spent on the phone, in offices, with specialists, with the computer, figuring out our lovely, friendly, supportive, helpful health care system. There are plenty of free services to help you get on the exchange. I have listed a few on the resources page.
  1. Listen: be an open, compassionate, willing ear to hear other people’s stories, and point them in the right direction. In an integrative review of Nurses’ experience of medical errors, Nurses reported feelings of restored personal integrity and were more likely to make constructive changes if supported. Supportive responses included discussing the error, offering advice, sympathy and verbal support, being respectful and discreet and expressing trust in the nurse (Lewis, Baernholdt & Hamric, 2013).

The following is from a book on medication errors (page 47 M. R. Cohen, 2007). Emily is a nurse who was fired after a newborn infant died from cardiac and respiratory arrest. She and the pharmacist involved discovered infant had been given 10 times the amount of the ordered drug by the wrong route. The pharmacist had accidentally sent up 10 times the ordered dose, and another nurse administered the medication. Emily was devastated. Criminal charges were brought. Emily states she felt humiliated. She needed support, not isolation from other nurses and health-care providers. She still worries about the nurses and the pharmacist involved. According to Emily, the isolation following an event is “just about the worst thing we in society can do to people”. Her advice to those seeking to support colleagues involved in error is to avoid directing anger at them. Sit down with them and go through the process of what happened, what went wrong – it is often so complex. After Emily’s trial, she was required to perform community service by telling other nurses her story of the dangers of medication administration. She has voluntarily continued these talks. She worries that those who do not acknowledge their errors have no one to talk with about their feelings. It is dangerous when providers ignore small problems and rationalize “it isn’t a big deal, we can fix it”

  1. Get some knowledge: there is a course offered by the World Health Organization: Patient safety workshop learning from error 2008 with “how to” fishbone diagrams for RCA and questions to consider on pg 24. There is a link to the course on my website. Read the Institute for Healthcare Improvement (IHI) white paper on Respectful Management of Serious Clinical Adverse Events (link on resource page). This is a comprehensive resource for responding to harmful patient events, which includes supportive actions for the second victims of errors. Susan Scott and colleagues have written a guide for implementing second victim rapid-response team after a harmful error. “The authors show how a dedicated team with knowledge and experience in supporting practitioners during the acute stages of emotional trauma can significantly aid the recovery of second victims.” And the book Patient Safety and Quality: An Evidence-Based Handbook for Nurses (Hughes, 2008) is available FREE online.

There are SO many books on failure and how to recover – I have listed just a few on the resources page. I had originally put everything I found when I googled failure, but I just read Shane Lester’s very short book about failure, and unfortunately can’t recommend it (good hearted, lots of grammar errors – so distracting!).

I am currently reading The Up Side of Down by Megan McArdle (2014) and really loving it. Here is a quote that speaks directly to my soul: “And by “previous failures” I don’t just mean a spot of bad luck…I mean deep, soul-crushing periods of misery following stupid mistakes that kept me awake until the small hours of the morning in a fog of anxiety and regret.” YUP – what she said. Totally. But then in the chapter on getting unstuck she talks about how “job loss” can be the best thing that can happen to a person by causing you to try things you would have never tried before (like starting your own business)

 

 

  1. Know your rights: Most of the time, you don’t have any. As I said, you can be fired for any reason at any time – as long as it doesn’t involved discrimination or retaliation. If you think you may have been discriminated against or retaliated against, seek legal advice – I have put a few sites on the resource page, but be aware that employees don’t have many rights. If a complaint is filed against you with the board, take a look at the complaint evaluation tool as well as the resources on the NCSBN site. Talk to trusted friends, and talk to trained professionals.

 

Charles Denham, chairman of Texas Medical Institute of Technology (TMIT), proposes five human rights for second victims, which can be remembered by the acronym TRUST:

Treatment that is just: second victims deserve the right of a presumption that their intentions were good, and they should be able to depend on organizational leaders for integrity, fairness, just treatment, and shared accountability for outcomes

Respect: second victims deserve respect and common decency and should not be blamed and shamed for human fallibility

Understanding and compassion: second victims need compassionate help to grieve and heal, and leaders must understand the psychological emergency that occurs when a patient is unintentionally harmed

Supportive care: second victims are entitled to psychological and support services that are delivered in a professional and organized way

Transparency and opportunity to contribute: second victims have a right to participate in the learning gathered from the error to share important causal information with the organization and to provide the victims with an opportunity to heal by contributing to the prevention of future events.

  1. Choose your next employer very carefully. Use the safe administration of medications checklist – sign up for my newsletter and you can get it for free, learn more about it in episode #2: Safe medication administration. It will help guide you in making a more informed choice about where you might want to work- it will help you be more careful and savvy about signing on with a company with poor safety standards. The checklist has a whole page of items to ask about before becoming an employee – things like “do you have the word safety in your mission statement?” and “how involved is the board of trustees in patient safety initiatives?” “what is your score on a measure of just culture?” Think really hard before taking a job at a facility that can’t answer these questions satisfactorily. You are putting yourself at additional risk.
  1. Take your time (if you can afford to) and wallow. Heal. Realize that you are not a bad person, or even a bad nurse. You are a human being, and therefore fallible. Resolve to make new and different mistakes.

After wallowing, at some point you have to bounce. You have to get back up. I may be really bad at many things: I have a big mouth, I can be rude, I can be abrasive, I don’t follow rules I think are stupid, and I have zero eye hand coordination with round objects (basketball bad). One thing I am really good at is getting back up. I am the Rocky Balboa of getting fired. You can take responsibility for your part in getting let go – that is important. If you don’t learn from your mistakes, you won’t grow, and you may continue to make the same mistakes (more on that later as well), but you don’t have to BE your mistakes. I spent weeks waking up every morning reliving moments from my (un) employment journey. I would wake up and before I realized I was awake, I would replay some incident from getting fired over in my head…and by the time I was fully awake I was in full shame mode. I asked everyone who knew me, “What is wrong with me? Why can’t I keep a job?” Those are good questions to ask up to a point. But it is also important to ask, “what is right with me?” “what job can I get that will bring me joy?” “what is it about my situation that I keep choosing jobs that I am not successful at?” I mean, I am a good person, for crying out loud! I am smart! I am funny! And (some) people like me!

At some point, you will end up flat on your back, the recipient of a knock out blow, and how you respond to that blow, well that’s what happens next, right? Do you get up? Do you go right back in there and get knocked out again? Or do you get up, dust yourself off, and step out of the ring, and say “this boxing stuff, it isn’t for me. I am good at a lot of things, but boxing isn’t one of them”. Don’t let the knock out punch determine your self-image. Let it teach you to find another way…to look for a dancing partner, or a blank canvas, or a keyboard, or a guitar, or a pad and paper…you don’t have to box.

Look at this list of failures:

Abraham Lincoln

[1832] – lost his job [1833] – failed in his business [1835] – lost his sweetheart [1836]- suffered nervous breakdown [1838]- defeated in his run for Illinois speaker [1843]- defeated in the run for Congress [1856] – defeated for US senate [1858] – defeated for the nomination of Vice president [1860] – Abraham Lincoln elected as the President of the United States of America

It’s entertaining to look at failures of sports figures, or politicians, or actors – it’s easy to see how they have turned lack of success around. The huge difference between their mistakes, and mistakes in healthcare, is that when a sports figure fails, no one gets hurt. Of course the team suffers, the athlete suffers, there is a loss of money and prestige and damage to reputation; but no one dies or is permanently harmed. The stakes of failure in healthcare are so much greater. I am trying to imagine a glossy healthcare video like the one from Gatorade (link on my webpage) with the tag line “turn defeat into victory”. In the video, famous sports figures talk about their numerous failures – people like Michael Jordan, Serena Williams, Lebron James. Would we put nurses, physicians and pharmacists up on screen saying things like, “I gave the wrong medication 6 times in my career, and in one of those errors, my patient went into a hypoglycemic coma for 3 days and was in the ICU. She lost vision in one eye…but I changed the way I practice, I began to utilize tools from the modern patient safety movement, and my safety record in the past year is stellar” In the world we live in, it would be impossible to find real people to admit to mistakes like that, but I can imagine the power behind the statement

What if the CEO of a major healthcare system came on screen and said “we had the worst record in the region for healthcare acquired community infections, but we have turned that record around and by hard work and perseverance, our record is now the best in the region.” Turn defeat into victory. We can only do that if we admit we have made mistakes. We can only learn from our mistakes if we feel comfortable admitting error, instead of feeling so ashamed, and frightened that we never speak of it. When I look at the advice that is given in books on failure (see the resource list for this article) it gives the message that it is totally ok to fail, but that it is not ok to give up. Yet what I have felt after making mistakes is deep shame accompanied by the feeling that I am a bad nurse, and maybe even a bad person. What if that isn’t true? What if we changed our paradigm in healthcare? What if we started saying to each other, and to ourselves: you didn’t make that mistake on purpose, how can we learn from that mistake to make everyone – you, the company, the patient, the family – stronger and less likely to make mistakes in the future?

So worst-case scenario –you know a nurse who gets fired for making an error in which someone loses their life, and she loses her license, and she can’t find another job. We could say the company that fired her is the bad guy – and we might be right. There is so much that needs to change in healthcare, and the adoption of a just culture is at the top of the list, BUT. Even though it is happening, very, very slowly, it hasn’t happened yet, and if you decided to go into healthcare, you have to realize – it could happen to you. Do you have a back up plan? Do you have support in place? Are you the sort of person who can be resilient? Can you bounce back?

SHOUT OUT: I can’t find any statistics on how many nurses get fired…anyone know where to find those, let me know. If you look at the board of nursing, you can see who is losing their license and who is getting disciplined – but so far that is all I have to report.

Update on Rose – I have decided to keep my updates on Rose separate, so please just click HERE to get all the updates since my first Blog on Rose and Consider Haiti

Thanks for reading or listening. I am working on my next few articles at the same time – I am not sure which will be out next, but look for alternative methods for pain management, and a riveting discussion of my research topic: “the effect of Root Cause Analysis on Safe Medication Administration Practice” – I just crunched some numbers and preliminary data is suggesting RCA training may support patient safety! Please sign up for the SFN newsletter to get exclusive access to photos from Rose, as well as the downloadable Safe Medication Administration Checklist, and updates on my latest articles, continuing education and resources. If you are listening, enjoy my dad, Bob Sanborn’s mandolin music as it plays me out. I started with a quote so I will finish with one:

Mistakes are the portals of discovery ~James Joyce

Resources

Quotes about Failure

Failure is your friend – a podcast from Freakonomics “Why are so many people so reluctant to quit projects or jobs or relationships that have soured? One reason, Stephen Dubner argues, is that we tend to equate quitting with failure, and there’s a huge stigma attached to failure. But … should there be?”

The Upside of Quitting – another podcast from Freakonomics “You know the saying ‘a winner never quits, and a quitter never wins.’ To which Freakonomics Radio says … Are you sure? Sometimes quitting is strategic, and sometimes it can be your best possible plan.”

J.K. Rowling – The Fringe Benefits of Failure – Harvard Commencement Speech (from her book Very Good Lives: The Fringe Benefits of Failure and the Importance of Imagination (2015)

Beyond Blame (1997) Documentary on medication errors (If you find a way to watch this for free, let me know)

A Hospital Accident: Lessons Learned – A Death, A conviction and A Healing – free TMIT webinar (2011) POWERFUL meeting between the father of a child who died from medical error and the pharmacist who committed the error. Captain “Sully” Sullenberger, who successfully landed a disabled plane on the Hudson River in 2009 also speaks.

Where to Report an Error – ISMP Error Report Tool (they also provide clinician support)

Medically Induced Trauma Support Services (MITSS)

Allnurses discussion board

Reddit discussion board

ProPublica Patient Safety Community

Show Me Your Stethoscope

Apply for unemployment (NC link, also has a link to NC Works)

Picking up the Pieces of Your Career and The Ultimate Career Guide for Nurses Donna Cardillo

Can nurses be sued for medical malpractice?

Employee Rights

Brown Law Office, P.C. “Because your healthcare license matters.” –Lorie Brown, RN, MN, JD.

Help with getting insurance

WHO Patient Safety Workshop: Learning from Error

Respectful Management of Serious Clinical Adverse Events – IHI White Paper

Susan Scott: Second Victim Rapid-Response Team

Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 2: Nurses at the “Sharp End” of Patient Care (2008) Hughes

Think Like a Freak (2016) Steven Levitt and Stephen Dubner “Levitt and Dubner offer a blueprint for an entirely new way to solve problems, whether your interest lies in minor lifehacks or major global reforms.”

Adapt: Why Success Always Starts with Failure  (2011) Tim Harford “Taking us from corporate boardrooms to the deserts of Iraq, Adapt clearly explains the necessary ingredients for turning failure into success.”

How to Fail at Almost Everything and Still Win Big: Kind of the Story of My Life  (2013) Scott Adams “Scott Adams has likely failed at more things than anyone you’ve ever met or anyone you’ve even heard of. So how did he go from hapless office worker and serial failure to the creator of Dilbert, one of the world’s most famous syndicated comic strips, in just a few years?”

Failing Forward: Turning Mistakes into Stepping Stones for Success (2007) John C. Maxwell “The difference between average people and achieving people is their perception of and response to failure.”

Mindset: The New Psychology of Success (2007) Carol S. Dweck “success in school, work, sports, the arts, and almost every area of human endeavor can be dramatically influenced by how we think about our talents and abilities.”

The Gift of Failure (2015) Jessica Lahey “…even though these parents see themselves as being highly responsive to their children’s well being, they aren’t giving them the chance to experience failure—or the opportunity to learn to solve their own problems.”

The Upside of Down: Why Failing Well is the Key to Success (2015) Megan McArdle “What separates those who keep treading water from those who harness the lessons from their mistakes?”

North Carolina Board of Nursing Employer Complaint Evaluation Tool

Disciplinary Actions: What Every Nurse Should Know – NCBSN online course (4.8 contact hours/cost $30) “Of all the complaints against nurses that go to state boards of nursing, between one quarter and one half result in disciplinary action.”

Grounds for disciplinary action when reported to boards of nursing Nancy Brent, RN, MS, JD

Gatorade – The Secret to Victory – when you need to feel inspired.

Additional References

Conway, J., Federico, F., Stewart, K., & Campbell, M. J. (2010). Respectful        management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement.

Denham, C. (2007). TRUST: the 5 rights of the second victim. Journal of          Patient Safety, 3(2):107-119.

deWit, M. E., Marks, C. M., Natterman, J. P. & Wu, A. W. (20). Supporting       second victims of patient safety events: Shouldn’t these    communications be covered by legal privilege? The Journal of Law, Medicine & Ethics, 852-858. Retrieved from: Supporting Second Victims

Hughes, R. G. (ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses. Prepared with support from the Robert Wood Johnson foundation. (No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality.

ISMP: Too many abandon the “second victims” of medical errors. July 14,         2011. Acute Care – ISMP Medication Safety Alert. Retrieved from:    https://www.ismp.org/newsletters/acutecare/articles/20110714.as p

Lewis, E., Baernholdt, M., & Hamric, A. (2013). Nurses’ experience of        medical errors: An integrative literature review. Journal of Nursing Care Quality, 28(2), 153-161.

Rassin, M., Kanti, T., & Silner, D. (2005). Chronology of medication errors         by nurses: Accumulation of stresses and PTSD symptoms. Issues in Mental Health Nursing, 26:873-886.

Schelbred, A., & Nord, R. (2007). Nurses’ experiences of drug administration errors. Journal of Advanced Nursing, 60(3), 317-324. doi:10.1111/j.1365-2648.2007.04437.x

Scott, S. D., Hirschinger, L. E., & Cox, K. R. (2008). Sharing the load.       Rescuing the healer after trauma. RN. December 2008:38-43.

Scott, S. D., Hirschinger, L. E., Cox, K. R., & McCoig, M., et al. (2010).       Caring for our own: deploying a system wide second victim rapid  response team. Joint Commission Journal of Quality and Patient    Safety, 36(5):233-240.

Seys, D., Scott, S. D., Wu, A. W., Gerven, E. V., Vleugels, A. et al. (2013). Supporting involved health care professional (second victims) following an adverse health event: a literature review. International  Journal of Nursing Studies, 50(5), 678-687.

Ullstrom, S., Sachs, M. A., Hansson, J., Ovretveit, J. & Brommels, M. (2014). Suffering in silence: a qualitative study of second victims of adverse events. British Medical Journal of Quality & Safety, 23(4). Retrieved from: http://qualitysafety.bmj.com/content/23/4/325.full

Wolf, Z. R. & Hughes, R. G. (2008) Chapter 35 Error Reporting and        Disclosure. From  Patient Safety and Quality: An evidence-based  handbook for nurses.

Wolf, Z. R. (2007). Health care providers’ experiences with making fatal         medication errors. In: Cohen M, ed. Medication Errors, 2nd ed.      Washington, DC: American Pharmacists Association; 43-51.

Wu, A. W. (2000). Medical error: the second victim. The doctor who  makes the mistake needs help too. British Medical Journal, 320(7237):726-727.

Safety First Blog

Update on Rose Katiana ~ Letters from Haiti

 

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I have decided to combine all updates since I wrote my first blog on Rose and Consider Haiti to make it easier for folks who are coming to SFN just for their Haiti fix to find information. What you find in this quick post has a repeat of some info from my 4th podcast on Safe Medication Administration. From now on, I will send out updates on Rose as well as access to all the photos she sends me through my newsletter, so be sure to sign up HERE.

From 4th podcast:

Rose Katiana is the wonderful woman whom SFN is sending to nursing school. You may recall from episode 1 about Haiti that Rose is an orphan. She shared with me that her mother died from complication due to diabetes and hypertension. During my two visits to Haiti as a nurse at multiple mobile clinics, about 50% of the people we saw had some combination of diabetes and hypertension. You can’t tell someone whose main diet is starch to eat “low carb” – protein is a rare and highly valued commodity, and not something widely available to Haitians. You also can’t expect them to reduce sugar and salt intake – two relatively inexpensive and widely available substances that make a Haitian’s day a little brighter. And don’t get me started on medications – when you don’t have a regular food source, purchasing medications isn’t on your to-do list. Rose’s mother would be alive if she lived in the US, because we could feed her good food, give her some metformin, and some ACTZ and get her blood pressure down. It is so frustrating. Her father died of a broken heart. He was a farmer and often worked in the fields around the clock ensuring his crops had enough water to grow – irrigation is a HUGE issue in Haiti – the weather is amazing for growing plants, but there is no way to irrigate the fields – no pumps, no way to dig wells. He became paralyzed – still getting the full story – and slowly wasted away lying in bed, wishing he was out in the field working. Last but not least, in episode 1, Rose told us a story about her friend Sandra – the little girl she helped by buying her some clothes. I asked about Sandra and found out she died in the Earthquake in 2010. I wish I had some good news. I guess the only good news is that Rose has some hope. She is getting English lessons, and will be going to nursing school in the fall. Remember, SFN donates 10% of all profits to Rose’s education through Consider Haiti. I hope you will consider a donation as well.

New information

(I am trying to keep Rose’s pattern of language – though I am not sure how well I do using google translate – will include her original email below if you are interested):

Rose has chosen to attend English lessons every Saturday – the course will go for 52 weeks, and lasts for 4 hours. She wanted to ensure that it wouldn’t conflict with nursing school (the girl is thinking ahead!). She was going to snap me a photo this last Saturday, but her cell phone battery went dead. 

You may recall that Rose is engaged to be married. She told me a little bit about Abel who resides Saint-Marc. He is the son of a Protestant pastor who plays music in church, he has trained in choir and has worked in teaching. Rose met Abel while taking rhetoric class, and have been in love for 3 years. His parents and her sister are aware of their engagement, and approve, but in Haiti, in order to marry, you must have at least one of 2 people working because they must have enough money saved to build or rent a house to live in, to buy furniture to put in the house and everything else they need at home to use. To set a date for the wedding, they need money to organize a reception for those looking to join the wedding. They also need money to pay for recording marriage. They need money to buy dresses and suits for new couples. 

I had asked Rose what she thinks the biggest challenge will be when she begins nursing school. Her answer: To me the biggest challenges will be my trips from Montrouis to Saint-Marc and from Saint-Marc to Montrouis because the road has crashes and is in disrepair and school will be dismissed at 8 o’clock at night. It will be hard for me to get a tap – tap to go back Montrouis then. But with courage and determination I come up to the challenge.

I am going to talk to the Consider Haiti folks to see if there is some employment for Rose and Abel to support their marriage. I am also going to talk to Rose about making friends at school so she won’t have to ride back and forth every day. I don’t know yet what time classes start in the morning, or how long the trip is from Montrouis/home to St. Marc/school. I thought that Eddy had said she would be living at the school, but I guess that is not the case.

Let me know if you have any questions you would like to ask Rose, Abel or her family. She and I write at least once a week (don’t you love email!).

Thank you so much for reading/listening to my articles – Contact me with questions, comment on my blog and podcast, and sign up for my newsletter to get a free downloadable safe medication administration checklist as well as exclusive access to all images that Rose sends me, and updates about Rose delivered directly to your inbox. I would love to hear from you – send me an email at safetyfirstnursing@gmail.com, or hit me up on social media.

Bonswa,

Kristi

Bonswa Madam Kristi,

Mwen espere oumenm avèk bèl pitit ou yo, mari-w yo tout byen.

Bô kote pa-m mwen byen gras ak favè Bondye.

Se toujou avèk anpil plezi map ekri-w  pou-m fè-w repons sou kesyon ou te poze-m yo.

Lekôl anglè a fonksyone pandan jou semèn ak jou weekend tou. Mwen te chwazi jou weekend lan(samdi) akoz lè-m prale nan lekôl enfimyè a se nan jou semèn mwen prale. Kou a dire 4 trè (4 hours) e lap fèt pandan 52 samdi.

Mwen santi-m byen nan fason pwofesè a dispanse kou a.

Abel abite Saint-Marc, li se pitit yon Pastè nan legliz pwotestant. Aktivite Abel fè se jwe mizik nan legliz, li antrene koral epi li travay nan ansèyman tou.

Mwen te rankontre avèk Abel pandan mwen te lekôl klasik (nou te nan klas retorik ansanm). Nou te vin zanmi e yon ane aprè(nan klas tèminal) nou te vin renmen (sa deja fè 3 zan). Nou te mete paran nou o kouran de relasyon nou an e nou te fiyanse.

Wi, mwen te di nap marye lè nou gen mwayen pou sa akoz nan peyi Ayiti men kijan sa fèt:

Fôk omwen gen youn pami 2 moun yo kap travay akoz fôk yo fè ekonomi pou yo konstwi oubyen afème kay pou yo abite, pou yo achte mèb pou mete nan kay la epi tout lôt bagay yap bezwen nan kay la pou yo sèvi. Lè yo kômanse avanse nan Pwojè sa a yo pran yon dat pou maryaj la fèt. Yo bezwen gen lajan pou yo ôganize yon resepsyon pou moun kap vin patisipe nan maryaj la. Yo bezwen lajan tou pou peye pou anrejistreman maryaj la. Yo bezwen lajan pou achte wôb ak kostim tou nèf pou moun kap marye yo. Si se 2 moun ki te deja ap viv nan kay gen depans ki pa nesesé, men nan ka pa-m nan nou se 2 jèn moun ki poko ap viv ansanm, tout depans mwen sot site yo ap nesesè.

Map pwofite reponn yon kesyon ou te poze-m nan yon lôt lèt men mwen pat gen chans pou-m te reponn ou. Se kesyon ou te mande-m Kisa-m panse kap pi gwo defi pou mwen pandan map aprann enfimyè a. Pou mwen pi gwo defi pou mwen se trajè Montrouis/Saint-Marc epi Saint-Marc/Montrouis akoz wout la toujou gen aksidan epi lekôl la ap lage a 8 tè nan aswè lap difisil pou-m jwenn tap – tap pou-m retounen Montrouis nan lè sa a. Men avèk kouraj e detèminasyon map rive leve defi.

Jodi an mwen tap fè foto pandan-m te nan lekol la pou-m te voye pou ou men malerezman batri telefôn mwen pat gen chaj, mwen pwomèt ou bb map fè yo samdi kap vini an. Mwen voye foto Abel ak foto paran li pou yo.

Mèsi pou sipô ak akonpayman ou banmwen pou-m kapab fôme tèt mwen.

Safety First Blog

You’re Fired: The Story of How I Lost My Job and Gained My Calling

You can listen to the podcast of the interview at THIS link on iTunes

Or you can listen to it on Stitcher

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.
This is a story of failure, and not just any failure – my failure; failure defined as the state or condition of not meeting a desirable or intended objective, being viewed as the opposite of success (Merriam Webster, 2017), being defined as getting fired. I’m going to tell you the details and how I dealt with it, and then how I wished I had dealt with it now that I am less in shock and more in recovery mode. Initially this was going to be one article, but it grew, and grew and grew. I have broken the article into two episodes – this one focuses mainly on what I did, what happened to me, and how I responded. Episode #6, which I am calling: “Have you been fired (or know someone who has?): resources for bouncing back with resilience.” Which will be out soon.
My goal is to provide you with resources and support – two things I lacked after I was fired. I would really like for anyone else out there who has been fired, or “knows someone who has been fired” to benefit from my experience. There is a resource page for you right over there. You can sign up for my newsletter and I will let you know when there is a new article, post, podcast, video or continuing education activity.

As a direct result of getting fired, I started Safety First Nursing. The mission of SFN is to support the psychological, physical and emotional safety of patients and nurses with education, resources and research. As I healed from the horrible experience of getting fired, and unemployment ran out, and I kept not getting a job, it occurred to me that maybe I might start my own business. My husband actually told me to do it…and I laughed at him. “I can’t do that, what would I sell? What would I do?” I came up with a million reasons why not. But the seed was planted, and slowly it sprouted, and grew. I am going to do an article on how to start your own business and the need for nurse entrepreneurship. If you want to know more about how to turn an educational activity into continuing education, I have a blog/podcast on that on my website, and you can always contact me. I would love to talk about how I can support your ideas.

On the website you can find a comprehensive list of patient safety resources, as well as continuing education with a patient safety focus. If you sign up for my newsletter, you will also get the latest updates on Rose’s journey through nursing school. Rose is a young Haitian woman I met through my work with Consider Haiti. Safety First Nursing is sending Rose to nursing school – 10% of all purchases of continuing education will go to Consider Haiti to support this goal. However, I just went ahead and sent the tuition, securing her a spot, and right now she is taking English lessons – a lot is happening. There is an update on Rose at the end of episode #6, so keep reading/listening.


Before I talk about my mistake, I want to talk a bit about error in general and how nurses involved in error are treated. As I have said in another article about safe medication administration – error is inevitable (Hughes, 2008). No matter how careful we are, we will make mistakes. Experts in the patient safety field have stated that nurses are at the “sharp end” of patient care, which is where the mistake is observed (Wu, 2000; Seys et al. 2013). However, the modern patient safety movement promotes targeting the blunt end of care – we have to hold systems accountable, we need to redesign systems to prevent harm from natural human error (Hughes, 2008).

We need to move away from punishing those at the sharp end of care with disciplinary actions, and focus on health care organizations and systems. Nurses are in critical positions to collect and assess data, work with interdisciplinary teams, examine performance, and drive evidence-based practice to improve patient safety. Hughes goes on to say that the foundation of quality and safety improvement initiatives needs to be centered on systems factors, not individuals. Nurse leaders, coworkers, and State boards of nursing must look at the impact of systems factors in any situation where the individual may be blamed. The responsibility of nurse leaders and State boards of nursing is to determine when errors and adverse events result from blameworthy behavior, and when they are a result of multiple systems factors. If we don’t look at the systems factors, firing the nurse won’t solve the problem – it will just trap another nurse at some point in the future and another error with potential for harm will occur (Wolf, 2007).

The blame and shame environment surrounding error causes many problems – many errors go unreported by health care workers. Even though a provider may feel relief at talking about error, there is always the concern about repercussions: disciplinary action, malpractice litigation and liability. Emotions reported include worry, guilt, and depression following serious errors, as well as concern for the patient and fear of discipline (Ullstrom et al., 2014). Many healthcare workers receive support most often from spouses rather than colleagues. Wolf & Hughes (2008) encourage us to admit mistakes, share them with colleagues as well as family and blow up that myth of perfection. When errors are reported, it is important to protect the reporters from negative consequences so fear of reporting is not reinforced. We lose so much data when only the errors that cause harm or those that can’t be covered up are studied and assessed. Other reasons for fear of reporting include prior experience with error – if a provider has made a previous error, even if the outcome was positive, the fear of reprisal is still there – no one wants to be labeled a bad nurse. We don’t want to intentionally harm patients; yet when we conceal errors, we place patients at increased risk of some type of harm (Wolf & Hughes, 2008).

 

In 2011, the Institute for Safe Medication Practice published a Safety Alert about a nurse who committed suicide after being involved in an error. It was called: “Too many abandon the second victims of medical errors” and a link to the article is on the resource page. Kim was 50 yo when she committed suicide on April 3, 2011, 7 months after making a mathematical error that led to an overdose of calcium chloride and the death of a critically ill infant. After investigation, the hospital terminated Kim after 27 years of service and for undisclosed reasons. Kim paid a fine and accepted a 4-year probation, including a requirement for supervision at any future nursing job. Just before her death she had passed an ACLS exam for a flight nurse position, but no job offers were coming in. Her partner reports Kim suffered from isolation, despair and depression. The ISMP is not alone in reporting that the healthcare industry has not implemented effective support mechanisms to address the personal, social, spiritual and professional crisis often experienced by “second victims” of fatal errors.

The response of the healthcare system is to punish the providers involved in the error, which can contribute to symptoms that look a lot like PTSD. The healthcare system forgets that when patient harm occurs, the involved practitioner also becomes a patient – one who will often be neglected (Rassin, Kanti & Silner, 2005).

The ISMP article summarizes some of the emotions and concerns felt after being involved in an error:

Immediate response: panic, horror, apprehension, disbelief, shock, increased blood pressure, heart rate, muscle tension, rapid breathing, extreme sadness, appetite disturbances, difficulty concentrating.

While awaiting investigation: fear of losing job, financial consequences of unemployment, fines, being labeled as incompetent or careless, loss of coworkers respect, involvement in a civil or criminal lawsuit, loss of professional license.

In the weeks post incident: Fear of returning to work, loss of confidence, self-doubt, remorse, depression, intrusive memories, excitability, nervousness, guilt, worry, embarrassment, anguish, humiliation, a wish to make amends, frustration and hyper-vigilance.

In the months post incident: characteristics of PTSD, inability to process feelings of fear, sadness, guilt and shame, insomnia, sleep disturbances, flashbacks, thoughts of suicide, damage self-perception, insecurity.

As I re-read these symptoms, I can honestly say I felt them all to varying degrees, and the incident I was involved in didn’t result in patient harm; it did result in termination of my position and a report to the board of nursing. About a month before the day I was fired, I had a visit with a patient who I will call PJ (names and identifying details have been changed i.e. there is no way you can figure out who I am talking about from what I am telling you). I had not met PJ before. The company I was with was in transition – it was a confusing time and patients were being assigned to clinicians with little time to prepare…sometimes the morning of a visit. We were moving to a care management model – one I really supported, but we were going through growing pains. I had been what was previously called an “admissions” nurse – I primarily did admissions visits. I would spend 1-2 hours with a patient and their family, gathering all the information needed to fill out all the forms for Medicare/Medicaid and the required Oasis documentation (which make about as much sense as a book that has been cut into pieces, thrown in a blender and then pasted back together). I typically spent most of my day filling out all those forms. I rarely developed a deep or lasting relationship with a client – I would see them once, sometimes 2-3 more times if a primary nurse couldn’t be found, but mostly just that one, in-depth visit. I would try to capture everything about them in that visit and transfer it to those forms, though it made no sense to me…to spend that much time getting to know someone, and then having another nurse take over their care, so I was really pleased at the idea of instituting care management. Nurses would be admitting AND managing patients – what a concept! However, since I was part time, I didn’t get to be one of the managing nurses, I got to be a helping nurse (I honestly can’t recall my title…support staff? Support hose?) –my main job was filling in, supporting my team (which was based on geography) by catching overflow visits. So I was seeing PJ for the first time – they had been admitted several weeks earlier and had a primary nurse, who just couldn’t get to them.

PJ really needed a visit. They had just come home from the hospital with a  PICC line (peripherally inserted central catheter) in his left upper arm. I can’t imagine the stress I would feel if someone I loved was on one of those things because here is a list of what could go wrong: battery failure, pump failure, line occlusion, infection, dislodging or accidentally pulling out the line, hitting a button and changing the infusion rate, or running out of medication.

PJ, however didn’t just have a PICC line with a continuous infusion, PJ was nonverbal. The voice box had been removed related to oral cancer 5 years previously. Due to the inability to take in foods orally, PJ also had a PEG (Percutaneous endoscopic gastrostomy) tube. PJ also had type II diabetes. PJ also had a non-healing ulcer on his left heel that required sometimes daily wound care. PJ also had a spouse. This was a complex patient. I read through the notes from the previous visits, starting with the most recent visit, which had been over a week prior, before the patient had been sent home with a PICC line. I would be the first nurse to talk to these folks after coming home with the drip. I imagined it would be a long visit, with lots of teaching.

I arrived at the patient’s home, and after knocking on the front door, was told to “come on in”. I entered through a screen door onto an enclosed porch to see the patient lying on a couch, finishing up a tube feeding. The spouse held a large syringe in their hand, which was connected to PJ’s feeding tube, and I arrived in time to see the last of a milky, tan fluid drain out of the syringe into the tube going into PJ’s stomach. The spouse twisted the syringe to remove it, and laid it on a table, and then replaced the cap to PJ’s PEG tube. The spouse turned to me as PJ stood up and shuffled out of the room saying “there is always nausea after a feeding.” Nurses who know about tube feedings may already have alarm bells going off in their heads – I certainly did. I knew from the notes that PJ had been getting tube feedings for close to 5 years, and I also knew the spouse was the primary care giver. I felt concerned about the position PJ was in when I arrived, which was far from the minimum 30 degree elevation recommended for a patient getting a tube feeding. I was also worried about the lack of a flush – typically you flush a PEG tube with water before and after feeding. My alarm bells went off. I recall thinking, “I wonder what is going on here…is something going on?” There were probably multiple small details that contributed to this thought, most of which I can’t even recall, but I have learned as a nurse to trust my instincts.

PJ was alert with no visible signs of distress. I scanned the PICC line set up as PJ sat down on the couch, visually checking for details that would let me know the PICC line and infusion were operating as expected. PJ nodded and made facial expressions that agreed with what I was saying. After getting a visual on all of PJ’s medications, and typing them all in to my computer, I moved on to the wound care.

The goal of home health is to discharge the patient – you provide temporary services, educating the patient and family to become independent with care, OR you determine that home health isn’t the right level of care for the patient and you get the ball rolling for finding them the level of care they need.

I was rapidly developing an attitude problem with the spouse, who was anxious, and kept saying things like “I just don’t know what to do” giving off a helpless vibe that irritated me. I remember with 100% clarity that I could have been MUCH nicer, and MUCH more patient. If you look at the nursing code of ethics, it is our job to care for the patient and family – as nurses, we aren’t supposed to let our personal feelings enter into the situation. I knew I was being a little rude…a little bit bitchy, and I remember thinking I should try to hit the reset button, but I didn’t. I gave a half-hearted attempt to appease the spouse, saying something like “I understand this is overwhelming and that you are under a lot of stress”, but it wasn’t working. Most of my focus, however, was on the patient. During the wound care I checked in, asking about feelings, and PJ continued to nod and give nonverbal cues of comfort.

We finished the wound care, and I began to talk about the PICC line. Line care is left until last if labs are ordered, because once you draw blood for labs, you need to get them to the lab. I always warn patients ahead of time, “once I draw these tubes, I need to skedaddle and get them to the lab so we can find out what is going on.” I try to wrap things up as much as I can before a blood draw. The order for PICC line care is to change the PICC line dressing, then draw blood, then change the caps. I explained the procedure and let them know that I had lots of experience with PICC lines and infusions, and that I would follow the doctor’s orders exactly.  I proceeded to follow the ordered care, while telling PJ what I was doing every step of the way. At one point I paused the infusion to change the caps – the infusion was paused for approximately 30 seconds – not long enough for the alarm to go off. I kept checking in with PJ, watching facial expressions, and receiving nods of confirmation whenever I proceeded to the next step. I finished the PICC line care and labeled the tubes of blood, and let them know what to expect next, when the next visit would be, and covered the usual teaching about when to call the home health nurse, vs. when to call 911.

I left the home, and sat in my car to chart. I meticulously charted every single thing I had done, including what I observed during the tube feeding, my teaching to patient and caregiver about proper tube feeding technique, as well as the wound care and PICC line care. My final assessment of the situation was that there was no abuse going on that I could observe, but that home might not be the most appropriate place for care. I knew we would be having a team meeting (a new feature of care management) and I would be able to talk about my observations and get input from the other folks visiting in the home.

A few days had gone by when I got a phone call from my supervisor. He asked me about the visit with PJ, specifically about the care I had provided. I told him what had occurred, and he agreed that it matched with my documentation, and that my documentation was correct and accurate and sufficient to show that I had performed the care according to orders. After a few more days, I was called in to meet with my supervisor and my boss’s boss. This is never a good thing. In my experience, they don’t call you in to say, “you are doing a great job and we want to give you a raise”. I knew I hadn’t done anything wrong, and when I checked subsequent charting on PJ, I could see no problems. I also had attended the team meeting about PJ and knew this was a person we were all concerned about –the team was on alert for signs the patient might need a higher level of care.

I entered the meeting with my boss with a sick feeling in my stomach. This was not my first rodeo. I had been in this room twice before in the last year. I had two write-ups on my record already. One was for documenting my times wrong – which I had not on purpose, it was more about the computer program used to document times, and less to do with me being a bad person. I do thank god for automatic time stamps, and I thank god we get paid by the visit and not by time. I had no motivation for charting the wrong time…it didn’t have any kind of payoff – it was just me being an idiot. The second write-up was for a patient complaint that I had tossed medications in the trash, which I had, with permission, because they were covered in filth. The social worker was a witness, and the patient had a back-up supply of medication (I will talk more on these issues later – just want you to know my record wasn’t unsullied). And yet, I kept telling myself that I hadn’t done anything wrong. Silly me.

Turns out that the spouse thought I wasn’t just a teensy bit rude, but had called in to complain that not only was I extremely rude, but that I had been asked not to do the PICC line care. I was stunned. I told my boss and my boss’s boss that I had been “less than nice”, that I could have been more sympathetic, that I wasn’t my best self. I told them how I had been feeling during the visit. I told them that at no point did I hear them say “don’t do the PICC line care”. I let them know that if I had understood that they didn’t want me to do the care, that I would not have done the care. I also said, that in retrospect, I wish I had been paying more attention to the signals the spouse was sending, and that a call to my supervisor would have made sense – to get support and help. They asked me many, many times to go over my conversations. At no point did anyone ask me about PJ – but I didn’t notice that at the time. I left feeling gross. I felt like a failure. I felt like I had let down my patient and the patient’s spouse. I didn’t sleep well, and was having trouble concentrating. I recall asking my boss, “am I going to get fired?” knowing the policy for 3 write-ups, but also knowing each write-up was for something different. Each time I had been written up, I had admitted my error and taken all recommended steps to correct it. I had not made any additional errors in either area.

About 2 weeks before I got fired, I was told I was being reported to the board of nursing. There is probably nothing worse for a nurse than to get reported to the board of nursing. I knew another nurse who had been reported, and I called her to ask for advice and support. She told me what she had been through, and that it had taken forever, and that she was still not fully recovered from the emotional trauma of the experience (the family of a patient accused her of ordering a referral for a patient without their consent). I went to the board of nursing web page and looked at the report policy and the discipline policy (links to these on my website), and tried to move forward with my job as if everything was fine…as if everything would be ok…as if I had done nothing wrong. No one from work called me to ask if I was ok, no one offered me support.

As luck would have it, I had taken an entire week off to travel to Haiti to lead a medical mission trip (more on that later). I had access to email during the trip and was told near the end of my trip that I had a meeting the Monday morning upon my return to work. See, in retrospect – it is obvious that I was going to get fired, right? But hope springs eternal. I am an optimist, and I tend to always think the best of people. I couldn’t imagine being fired for this situation (the patient was unharmed, I had never been told not to do the procedure, I followed orders)….and I could totally imagine being fired for this situation (I was rude. I was RUDE. I WAS RUDE!!!). And so I returned from Haiti, went into work Monday morning, and was escorted to human resources, where I was fired.

I remember feeling numb coming into work that morning, knowing it might happen, but hoping for the best. I had my laptop and my phone (as a home health nurse, you really need those things sutured to a body part), but that morning the minivan battery was dead (thank you wonderful children, for leaving a door open) and I didn’t have any of my supplies (I had a plan to return home after the meeting and get the right car after a nice charge from AAA…if I still had a job). So it all ended there in that meeting with my boss, and my other boss and my boss’s boss and the HR lady saying, “you are terminated”. They told me why (patient complaint, not following procedure, poor leadership), and asked me to sign a form – I asked if I could sign later…I was in shock. I heard them say “sure”. I asked if anyone had wanted me to stay? Had anyone fought for me? “no, this goes all the way to the top”. No one. It was unanimous. Unanimously fired. I told them something like, “you know this is ridiculous. I am a good nurse, and I do so many things well. You have told me I do so many things well. Why in the world would you fire me? What a waste of money…all the training and experience, down the drain. I loved working here. Why not find me something else to do in the company that I am better at?” The response? “we don’t do that – it’s your job to ask for help, to explore other options”. I felt angry, sad, confused, humiliated, stupid. I turned in my computer and my phone. I refused to sign the termination papers, asking if I could come back later in the week to sign when I was feeling less in shock and was told “yes” (NOT TRUE! – once you are fired, they don’t have to give you any information). They walked me to my car with a security officer (in case I snapped? In case I did…what? I was wondering what options I hadn’t thought of…what things could I possibly be doing that might require a security guard?) I remember saying “what should I do with the centrifuge and the other supplies that belong to you guys?” They said I could call and make arrangements to meet someone off campus to return them – not allowed back for 2 years. I forgot to ask about insurance…I drove home, leaving without a copy of the termination papers. I texted my husband and friends. I sat down on my bed and stared at the wall, thinking “at least I have the day free…”

What in the world to do? There are so many resources for healthcare workers involved in an error if they still work at the facility where the error occurred. But what was I supposed to do? Oh, and I should tell you – before you feel sympathetic to me, this is not even the first time I have been fired (more on that later as well…fired from 2 different nursing education jobs for being…well, for being rude. I have a bad habit of saying what is on my mind…terrible idea.)

List of things I knew I needed to do:

  1. figure out health insurance
  2. file for unemployement (?)
  3. deal with board of nursing
  4. look for another job
  5. freak out
  6. freak out some more
  7. contact a lawyer (?)

Here are a few pieces of advice regarding things I did right:

First of all, if you even think you are in trouble, though it is VERY important to admit that you did something (see the resource page for the Complaint Evaluation Tool used by the board of nursing to evaluate blameworthy behavior), it is also probably not necessary to grovel. I wish I had said less. Did I need to admit I had been “less than nice”? yes, but I could have said “I had some difficult conversations with the patient’s wife” because in retrospect – the reason I was “less than nice” was that I was truly, deeply concerned about her ability to care for her husband safely. The definition of fraud is to try to cover something up. Don’t do it – you may lose your license.

Second – GET OUTSIDE SUPPORT. I saw my therapist, and she is awesome, but what I really wish I had done was talk to a professional nurse – someone else in home health, maybe someone who didn’t work with me, maybe someone who didn’t even know me. But how to do that? How to find someone you can trust? And who wants to talk to someone about a failure? Nurses are judgmental – we don’t tend to be kind and understanding when confronted with another nurse’s error – we tend to say “why didn’t you follow the rules?” “you should have been nice”. I was afraid to tell anyone anything…. Of course my friends and family would “side with me”. I couldn’t get enough clarity in the weeks following the error to ask the right questions or make the right statements.

An example of this is the clarity I got during my interview with the board of nursing. It happened about 2 weeks after I got fired. It was just me and a nice lady from the board. She asked me a LOT of questions, but the most important question she asked me was, “well, what did the patient say?” in other words “did the patient give consent?” and I suddenly realized the answer was YES. If I could go back and say that to my boss and my boss’s boss and my boss’s boss’s boss, maybe I would still have my job.  After an hour interview with her, she let me know I would be informed within 4 weeks of any disciplinary action/loss of license etc…no big deal. No big deal. Just 4 weeks to wait to find out if I get to continue being a nurse…to find out if I get a disciplinary action on my license (which is a public action that anyone can find on the website for the board). Makes looking for another job feel SUPER!!! (sarcasm). I would change nothing about how I handled my interview with the board. I was completely honest, and that is something you should be as well. They have ALL the information, so there is no point in leaving anything out, or making anything up. She had a list of every patient complain I had ever received. I didn’t remember most of them – I don’t keep a log-book of them – but maybe we should all start? I guess I just assumed we all get patient complaints? Is there a way to know you are getting more than you should? Is there a minimum number that means you have to go stand in the corner? If they were serious, why wasn’t I written up? I am still not sure how that works – a patient calls and complains, and they write it in your file, but you don’t know about it, or if you do know about it, it’s because your boss called you on the phone and asked you about it, but you never sign anything, or see anything, or know that it’s part of your record until you realize the freaking BOARD OF NURSING has it!

I wrote in my journal and talked to friends and family and my amazing husband, who told me to take my time. They all said to take my time (can’t emphasize enough to take some time off if you can swing it), and supported me, and told me “this happens to nurses all the time” (but I am thinking, yeah, but not to ME). I spent an entire month watching Netflix (got totally caught up on the Walking Dead), doing yoga, exercising, meditating, going to therapy, cleaning, doing yard work, having really long lunches with my girlfriends. I wallowed. Wearing your jammies all day, wandering around the empty house, eating your body weight in ice cream, smoking the occasional cigarette (I know, bad bad bad). It was good stuff. But I really should have gotten some additional help. I had no idea there was support out there. I didn’t know I could reach out to discussion boards on Allnurses or Reddit. I didn’t know that Donna Cardillo has books and blogs and support for nurses who have been fired. I didn’t initially know that I could post on the ProPublica patient safety community and get instant support, and a phone conversation with Marshall Allen, the guy who moderates it. That conversation with Marshall Allen was enlightening – he said “it doesn’t sound like you were involved in an error” and I responded, “but I was, the error was….” And then I stopped. What was the error? I was rude. I spoke truth to someone who didn’t want to hear it. I provided the right care at the right time to the right person in the right way with the right documentation. I have a big mouth, and that may be my biggest ongoing error.

I asked everyone I knew – what support is there for nurses who are fired? But no one had answers. The ProPublica post I made this spring finally opened the door to patient and family advocates, to resources and organizations I didn’t know existed (see my resource page for all of this good stuff). I made contact with a patient safety advocate I met on the ProPublica site and we had coffee and shared stories. She recommended I check out Show me Your Stethoscope, another Facebook page providing support for clinicians.

Other advice I would give includes your attitude towards the company that you work(ed) for. After getting fired, the first place my mind went was, “they suck” in various forms. I would replay events from the incident over and over in my head, with different outcomes that relied on the people above me behaving differently, or that relied on the company changing the rules. It was a fantasy world that did not help me heal. There is an idea out there that the company involved in an error is the “third victim” – that they suffer as well. What good does it do anyone to blame them? If I am angry with them, where am I? I am a person without a job who is really angry all the time. They didn’t allow me to be better, but I am not allowing them to be better. We all missed an opportunity for growth.

In addition, you may be harming yourself. This was passed on to me from someone I met on the ProPublica site: larger corporations may have “reputation repair” specialists looking out for their brand – it’s how they catch people doing stupid things on social media. You mention your workplace by name and post a photo of your patient and they find out. Sometimes they find out because another co-worker tells them, but it can be through surveillance as well. Ranting about the company that fired you in highly specific terms can lead to a lawsuit against YOU. It is ok to talk about how much it hurt to be fired – to talk about what you went through, but be circumspect and respectful. Your opinion may also change as you move away in time from the incident. The more time you give yourself to heal, the more you may find you can see the part everyone played in what happened. It’s the old – one door closes and another opens – your attitude about what happened can affect everything in your future.

I also went to the National Patient Safety Foundation Congress in May, and stood up in front of about 1000 people and told them I was fired for being involved in an error – and it felt really good. I got a lot of support and found out about Medically Induced Trauma Support Services (MITSS). Plenty of nurses and clinicians listened to my story. I don’t feel like it’s enough. There is simply not enough support or information out there for nurses who get fired. We need to widen our net, we need to tighten the mesh, we need to make sure that the next time a nurse gets fired, he or she immediately knows where to get help.

I hope this has been meaningful to you. It was really hard to write. I still feel embarrassed and ashamed. I am worried you will judge me – that you will think I am a bad nurse, or even worse a bad person. I am worried folks will write really mean things. I am worried admitting to all this stuff will damage my reputation. But I have decided to make a difference. When I started SFN, I knew I would be sharing my story. Sharing stories is how we heal. If just one person is positively affected by what I write, then it’s worth it. Please contribute to this discussion on my website – there’s a discussion board for this episode – and contact ProPublica (it’s easy!) and share your story with Marshall – he is collected stories of nurses involved in error. Email me with your story – we can re-write it to remove identifying details – but it’s SO IMPORTANT to share, to stop hiding in shame, and to support one another. Let’s get the conversation started.

Episode 6 is in the works – it will include the resources you need to survive getting fired, as well as an update on Rose. Thanks for reading, and if you are listening, enjoy my dad’s mandolin music on your way out.

Resources

Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 2: Nurses at the “Sharp End” of Patient Care (2008) Hughes

Chapter 35: Error Reporting and Disclosure (2008) Wolf & Hughes

Too Many Abandon the “Second Victims” of Medical Errors – ISMP The story of a nurse who committed suicide after being involved in the death of an infant

North Carolina Board of Nursing Employer Complaint Tool

Allnurses discussion board

Reddit discussion board

Picking up the Pieces of Your Career and The Ultimate Career Guide for Nurses Donna Cardillo

ProPublica Patient Safety Community

Show Me Your Stethoscope

Medically Induced Trauma Support Services (MITSS)

Where to Report an Error – ISMP Error Report Tool (they also provide clinician support)

REFERENCES

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Hughes, R. G. (ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses. Prepared with support from the Robert Wood Johnson foundation. (No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality.

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Scott, S. D., Hirschinger, L. E., & Cox, K. R. (2008). Sharing the load.  Rescuing the healer after trauma. RN. December 2008:38-43.

Scott, S. D., Hirschinger, L. E., Cox, K. R., & McCoig, M., et al. (2010). Caring for our own: deploying a system wide second victim rapid response team. Joint Commission Journal of Quality and Patient    Safety, 36(5):233-240.

Seys, D., Scott, S. D., Wu, A. W., Gerven, E. V., Vleugels, A. et al. (2013). Supporting involved health care professional (second victims) following an adverse health event: a literature review. International  Journal of Nursing Studies, 50(5), 678-687.

Ullstrom, S., Sachs, M. A., Hansson, J., Ovretveit, J. & Brommels, M. (2014). Suffering in silence: a qualitative study of second victims of adverse events. British Medical Journal of Quality & Safety, 23(4). Retrieved from: http://qualitysafety.bmj.com/content/23/4/325.full

Wolf, Z. R. & Hughes, R. G. (2008) Chapter 35 Error Reporting and Disclosure. From Patient Safety and Quality: An evidence-based handbook for nurses.

Wolf, Z. R. (2007). Health care providers’ experiences with making fatal medication errors. In: Cohen M, ed. Medication Errors, 2nd ed. Washington, DC: American Pharmacists Association; 43-51.

Wu, A. W. (2000). Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal, 320(7237):726-727.