Two nurses make a medication error: One causes an adverse event with a patient and the other does not. Should the nurses be disciplined, and, if so, should they be disciplined the same way? Why or why not? How would this be addressed in a just culture
Discussion 2-2: Patient Safety
Healthcare organizations should outline in their patient safety cultures clear procedures to handle patient safety events such as medication errors committed by nurses. The type of disciplinary action taken against nurses who make medication errors vary from one state to another and follow the guidelines documented by Boards of Nursing (BON) (National Council of State Boards of Nursing, 2022). When two nurses make a medication error like in the given scenario, both of them should face disciplinary action despite the fact that one causes an adverse event with a patient and the other did not. The reason is that in both cases, there is evidence of inappropriate medication use by licensed nurses who are charged with the responsibility of ensuring patient safety (National Council of State Boards of Nursing, 2022). However, due to the variation in the severity of the medication error consequences, the two nurses should be disciplined differently but in accordance with the laws set by the State Board of Nursing. For example, the nurse whose medication error caused an adverse event can be suspended from practice for a period of time while the other nurse can be compelled to complete a nursing course on patient safety (Academy of Managed Care Pharmacy, 2021).
Alternatively, an organization can utilize the just culture approach to address patient safety events. According to Rogers et al. (2017), a just culture encourages open dialogue between an organization and its employees and allows continuous improvement of processes to promote safety and protect patients from harm attributed to medication errors. Precisely, the facility should work with healthcare providers to classify actions that qualify to be medication errors and that might put patients at a great risk of harm. They should work together to set realistic expectations, train staff to improve their pharmacological knowledge, and develop policies to encourage accountability (Rogers et al., 2017). A just culture will increase patient safety by maximizing reliability among the staff and preventing future patient safety events.
Academy of Managed Care Pharmacy. (2021). Medication errors: Concept series. amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors
National Council of State Boards of Nursing. (2022). Board action. https://www.ncsbn.org/673.htm
Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to managing medication errors. Hospital Pharmacy, 52(4), 308–315. https://doi.org/10.1310/hpj5204-308