It's been more than a decade since "To Err is Human" and the feedback from this story indicates that we're still not learning the message. All humans make mistakes. Our only hope is to design systems that provide enough safety checks that risks to patients are minimized. To do so, we need open, honest feedback about how errors occur and nurses and other clinicians will only do that when they do not have to fear they will lose their jobs and their livelihoods.
No nurse goes to work thinking, "I'm going to harm a patient today." When something bad happens, it's an incredibly emotional experience for all involved.
Gayla Jackson, RN, BSN, a nurse manager of a busy medical unit, knows first-hand what it's like to have the unthinkable happen. About 15 years ago, she was working as a staff nurse on a busy ICU step-down unit when one of her two patients coded. As things began to calm down, she took a telephone order from the physician of her other patient requesting an IV push of heparin.
Jackson says she listened to the order, then returned to the emergency still in progress. Once the situation was stabilized, she went to administer the heparin to her other patient. She drew up 9,000 units and had a coworker check the dosage, per protocol.
After administering the medication, Jackson says she broke out in a cold sweat. She realized the physician had said 900, not 9,000, units. She still remembers the feeling of dread that broke out when she realized what had happened.
"As soon as I did it, I knew it was wrong," says Jackson. "Your whole body just goes cold. You feel like you will faint. Everything stops and everything flashes. You think, 'I can't go on.' How can you even breathe thinking about what just happened?"