I will admit that recently I made a med error. I ALMOST NEVER make them. I gave a 10mg Norco instead of a 5mg Norco. Everyone will make mistakes. there is a culture of terror and punishment and blame in healthcare. And the focus of say, JCAHO or "the state" is all wrong. It is all about punishment and blame and NOT about HELP and support and education. I love this post. Thank you.

I've been in EMS for a few years here in Texas! I just recently became a nursing student and I am proud to say that I got to share you with them! There are now 36 more good students working on being great nurses! Thanks to you Z and your entire crew! Love the education and perspective that you put into each discussion! From the poppin rap skits an the soap box to the waving a warning sign before the accident up ahead. A lot of them took a little something extra home that day! This is topic is the subject of 25% of our over all grade for Foundations of Nursing. We will present a mock trial and then create our own AEB learning from all that happens. This HAS to be more than just a punish and enslave moment. This needs to be a protect and serve! Thanks for all you do!

I view things a bit differently. There’s a correlation with greater workloads on providers & medical mistakes. Hospital systems are squeezing workers more & more every day. Yes, systems should always be optimized to prevent mistakes, but rarely does anyone look at increasing workloads contributing to mistakes b/c that’s a fairly nebulous pursuit. I’m an hospitalist & when I’m forced to see a ridiculous number of patients my decision making is not the best. Few docs will ever say that.

The biggest system problem is when organizations extract more and more measurable productivity from fewer and fewer personnel--this creates a pressure which can distort all decision-making.

I feel so bad for that nurse. I made a medication error in nursing school, gave a digoxin to bed 1 that was ordered for bed 2. I reported my error, monitored the patient, learned from it, and never made another one in my nursing career. I was recently in the hospital and there were multiple medical errors on me made during my 10 day stay. I think I caught most of them, hopefully.

I am so thankful for you touching on these topics, I have learned a lot from them and I love hearing how others see these things as well. It’s hard being a RN, we are mostly extremely caring compassionate people who want to help others. I could write a book on reasons we may make mistakes, and I may fuss a lot about the steps my job puts us through but it is wonderful knowing it’s to protect me and my patient. I can say there are times we have so many numbers in our head and when we draw up someone’s insulin we took a little to much or a little to less but with that second Rn signing it and repeating it to the patient it has always been caught. That’s comforting kinda like hey if I am going down your going down with me! ❤️

Such a tragic story...Definitely a lot to learn from a situation like this

As a newer nurse, blank canvas going into the field out of nursing school; personally I see how nurses in general are stretched thin. And what after that? I think that maybe nurses wouldn’t want to skip or override things but at the same time, timing is certainly an issue. Putting patient caps for hospitalists rounding floors and nurses, I think would minimize these errors. People would actually take time to do things because they would HAVE the time. Sure overriding things and cutting corners is not what we get taught and we shouldn’t do it but I see why people do. Unintentional errors can be avoided I think if time could be allotted for health care providers to do what we need to do. I think that it’s scary for nurses because we get told “at the end day you gave it” and that’s terrifying to go to work and think that. There are many hands that meds go through before a nurses and yet somehow it’s on the nurse. Not saying that other health care providers don’t feel it, but blaming a person is not it. That’s not how the healthcare system will get better. It’s a group effort and I hope we get there one day. At the end of the day we are there for the best outcome for our patients.

It’s interesting how errors in medicine vs other fields are treated differently.

I think if you are going to speculate about a nursing process, you should get a nurse or two to discuss it with you...

It has been my experience that blaming someone is perfectly acceptable, and yes it will shatter them if they have not already torn themselves apart. However; to abandon them for a mistake that anyone could make, and then to turn that person into a villain and/or scapegoat just to save the face of an organization is where my experience has been drastically different. We build each other back up, take a long look in the mirror, and adapt the "status quo" to reduce the odds of a repeat occurrence. It may not be popular but I do not think she should have been fired. I feel that she could have been laterally moved to another (less stressful department) to aid in her emotional recovery and encouraged to speak at new employee/quality improvement meetings as an example of how easy mistakes can be made when protocols are not followed and how devistating the consequences can be to all parties involved.

She is already blaming herself and she do regrets what happened to the patient. She need counselling and maybe she can be a part of what need to be improved to prevent it from happening to someone else.

Thanks for showing compassion. It’s so hard when people shout down mistakes nurses make. (And comparatively, we make less mistakes). But we are human. We have processes in place so that this would take more work to make happen than to make the error happen. But 99.999999% of nurses because nurses to save lives, make lives better and when the time comes, help transition peacefully. I don’t know how I’d live with myself if I made that mistake. Again, the nurse is accountable. But her team should be too. When in a hemorrhage, if I’m drawing up and override med, I shout it out, “Morphine 2mg IV to Sonya!” Then Sonya will shout, “Morphine 2mg in and flushed!” It’s probably disconcerting to the patient, but it works. I can explain why we do it that way later.

Zdogg, if you wanna learn about the nursing process for hospitals and meds i think you should shadow a nurse for a couple hours, would love to see your take on it

She was found guilty today of criminally negligent homicide and abuse of an impaired adult, will get 12 years in prison

Thank you for addressing this

I made an error as a pharm tech and my mom made one as an LPN...but the worst was one I made on myself. I was half asleep and flushed my central line with a syringe I had used in my G tube. I’m so lucky I only got staph epi and that I reported what i had done. I had none of the typical bacteremia symptoms. I can only imagine how it is on exhausted nurses with multiple patients.

So glad to see you've backed down from blindly immolating the nurse without considering the million other factors that allowed this to happen. The original show DID have you blatantly blaming the nurse to the exclusion of all else.

What if the Pyxis verbalized the drug+dose as the med is selected and/or as the droor opens?

I read the account provided. The glaring thing to me is this: NEVER interview about any incident, event, anything at all involving your nursing performance while at home or on the phone. Never ever. Who ever is requesting the interview should make an appointment during normal business hours at the facility. You/nurse should then attend the meeting with your lawyer. I read that several of these interviews were done over the phone. Bad move on everyone's part. How all the evidence is handled and who was involved in the process is very important and proper representation should always be procured.

Working in industrial operations has ruined me bc I can't think of this without Human Performance tools coming to mind. STAR/Self-Checking, Stop when unsure, Task preview/Jobsite review, Questioning attitude, Peer checks, Procedural use & adherence, and 3-way communication are beat into our head at every shift. AHA has a lot of this with the ACLS/BLS team dynamics portion of class. I have been part of a med error (versed instead of fentanyl) caused by not doing a peer check on my partner. We self reported and I'd like to think that coupled with no patient harm being done kept us employed.

The systemic change is warm bodies with the patient not understaffed amazing nurses and doctors being put in a stupid understaffed situation

I have a horrible story to tell I need someone like you to expose it. Please contact me. I love your show.Thank you for all that you do.

Ultimately I think this obsession with shielding people from the results of their actions is just as unproductive as pretending there aren't system elements at fault here as well. The problem is that when you clean kill a patient by overriding a system, fail to either be competent enough or diligent enough to notice they have the wrong drug, don't notice this med shouldn't need reconstitution, and finally don't ensure the patient is monitored (even a minute of sitting there should have caught this) then you arent fulfilling your duty to the patient and shouldn't be in your given position. We all make mistakes. Not all mistakes are of equal magnitude or outcome and not taking that into account is nonsense. Also, by all means we should continue to search out and improve system shortcomings, but those are there to assist you. They dont alleviate you of your ultimate responsibility to not kill people.

I’m very glad that you addressed the Vanderbilt issue in terms of just culture. I’m a nurse and the first thought that came to my mind when I first heard about this incident was how terrible the nurse involved must feel. I also hope/hoped that the hospital used this incident to improve their processes so the same kind of mistake doesn’t happen again. I have been VERY fortunate to work at facilities that support just culture. And it’s true that people should be held accountable for their actions but placing blame isn’t enough. We need to continue to improve our workflow so that we can provide safe and effective care for our patients.

What do you have in the safe doc ?

Hopefully the organization has a Second Victim support program. Mine does and in addition, we do follow just culture processes in all patient error events.

My feeling is that the manufacturer should have packaged it in maybe a more alerting attention, to the drug. Like maybe a completely red container! 🤔

What if it asked a multiple choice question? WHAT CLASS OF BLACK BOX DRUG ARE YOU TRYING TO PULL FROM THIS PYXIS? A Anticoagulant B Antipsychotic C Sedative D Paralytic agent E Blood glucose lowering agent

Why fire the nurse AFTER she’s learned her lesson? I agree that there should be accountability. Epic generates reports on each nurse’s compliance with medication scanning. If a nurse continually refuses to consistently scan meds despite education and warnings, fire him or her BEFORE there’s an error. If a mistake was really a mistake, recognize that they happen anywhere humans work and try to make the environment safer.

I have some amount of cognitive dissonance about this case. I somehow have placed this nurse to be more accountable for this death, than I did for Dr. Bawa-Garba in her situation. It might be the horror aspect, or the clearly visible aspect of negligence in this case. It may also be that I sympathise with the doctor more because I'm currently on the path to become one and can't comprehend what my life would be like if I were to eventually lose a medical license. There's also heaps of points during this case where, if the nurse had actually done her job properly, this tragedy could have been prevented. Anyway, despite having thought about this quite deeply over the past few days, I still don't really know how I feel. Especially, as my non-medically interested bestfriend put it, "worse tragedies than that happen everyday in the States cause children have access to firearms." :/

The problem is very complicated with multiple factors and professions/institutions involved. I don't see a resolution to this anytime soon. Shit rolls down hill and front line healthcare workers are at the bottom.....

I snorted three grams of vecuronium , and i didn't even catch a buzz (shake my dickhead twice) I called my people back for a complete refund !!

Culture should be such that even near misses should be reported without fear.

I love that my hospital has the best policy ever all pet scans are outpatient. No inpatients get a pet scan and for those outpatients that you want to treat claustrophobia you get an Ativan or a Xanax. There are only two docs in my whole hospital who can read pet scans so it’s a very linear or for we efficiency people it is a very lean and six sigma process. Any hospitalist who orders a pet scan instantly gets a big swift ha ha ha ha. Although I don’t do it anymore I was that nurse who takes people down for procedures.

Nice

I feel sorry for the nurse.

3:00 It is 1000000% appropriate, especially when the person GOES OUT OF THEIR WAY to bypass safety protocols. Anyone who defends the nurse is just as bad as she is.

Medical Industry does need a Re-Boot /revamp. Blows me away We r drilled on all types of knowledge to care for people Yet staff is not treated with same love. Medical Industry needs to remember we r human. IMO those in the industry Need to speak up give constructive feedback and work towards a better world. When u speak of culture: I find there to b a culture of need for perfection & who is the smartest. In this case tho we do have to admit a error killed a human: that is real.

And, we are gonna run out of medical personnel, because people are afraid to go into the vocation!

I’m so glad you talked about this. I live in Nashville. On an unrelated note, there was an ambulance transporting a patient from west TN to Vanderbilt. It was raining and the medic hydroplaned causing her partner and the patient being transported to be thrown from the vehicle. They both later died while the driver had only scratches. I don’t blame her. She may have only walked away with scratches but she’s got scars that she will live with forever. People wreck all the time. How could I blame her?

Fire people who are not the ones who need to be there but the understaffed system dedicated to charting and bull crap keeps staff away from people

Sorry for the drunk kinda ex nurse crap, I know how smart yall are, just venting

The issue is that this was beyond risky, the nurse bypassed multiple barriers to keep this kind of error from happening. This was reckless she didn't consult a doctor and in doing this took the responsibility upon herself that she knew what she was doing and made several mistakes that ended with someone losing their life. charges should be brought. The general public get charged for reckless deadly accidents, engineers get charged for cutting corners during deadly failures in their design.

The doctors and nurses are "privileged" thus will never go PRISON in the hellth care system for the cattle(patients).

Firing someone under these circumstances is counterproductive. She will never make a mistake like this again.