Field of study: Nursing (Minimum of 250 words with peer review reference) 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?
In the field of nursing, medication errors are an unfortunate reality that can lead to adverse events for patients. When two nurses make a medication error, it is important to consider whether or not disciplinary action should be taken, and if so, whether the same disciplinary measures should be applied to both nurses. This issue can be addressed through the lens of a just culture, which focuses on creating a fair and transparent system of accountability that promotes learning and improvement rather than blame and punishment.
In the case of a medication error resulting in an adverse event with a patient, it is essential to investigate the circumstances surrounding the error before determining disciplinary action. Factors such as the severity of the event, the nurse’s level of responsibility, the presence of any mitigating circumstances, and the nurse’s past performance should all be taken into account.
Disciplinary action should be based on a fair and evidence-based approach that considers the specific circumstances of each nurse’s involvement in the medication error. This means that if one nurse’s error was more severe or potentially avoidable than the other, they may warrant a different level of disciplinary action. For instance, if one nurse mistakenly administered a medication that resulted in a minor adverse event, while the other nurse made a critical error that caused a serious harm to the patient, it would not be fair to treat both nurses the same way.
A just culture places a strong emphasis on learning from mistakes and improving the system to prevent future errors. This approach recognizes that individuals are fallible, and that errors can occur even among competent and conscientious healthcare professionals. It is important to foster an environment where nurses feel comfortable reporting errors and near misses, as this allows for early intervention and system improvements.
In a just culture, disciplinary measures are not solely punitive but are designed to address both the individual’s actions and the underlying factors that contributed to the error. Disciplinary actions can range from educational interventions, such as additional training or mentoring, to formal reprimands or even suspension or termination in cases of gross negligence or repeated errors. The goal is to ensure that nurses are held accountable for their actions, but also to provide them with the opportunity to learn and grow from their mistakes.
Furthermore, a just culture places equal emphasis on system redesign to identify and address any contributing factors that may have led to the medication error. This includes evaluating medication administration processes, communication protocols, and technological systems, among others. By addressing these underlying system issues, the likelihood of future medication errors can be reduced, creating a safer environment for both nurses and patients.
In conclusion, when two nurses make a medication error with differing outcomes, disciplinary action should be determined on a case-by-case basis, taking into consideration the severity of the adverse event, the nurse’s level of responsibility, and any mitigating circumstances. A just culture approach promotes fairness, accountability, and learning from errors, rather than focusing solely on blame and punishment. It encourages a proactive approach to preventing future errors by addressing both individual actions and system factors. By implementing a just culture, healthcare organizations can create an environment that supports open communication, transparency, and continuous improvement in medication safety.
Reference:
Prezas, R. F. (2016). Just culture in nursing: A meaningful approach to promote safety and quality. Journal of Nursing Regulation, 7(3), 35-40.