Credits: None available.
Patient safety became a focus of modern health care when medical errors became news. This session is a primer on the ethical and regulatory requirements for error reporting as well as the current guidelines and best practices for reporting. The application of medical professional apology statutes are also highlighted.
Contact hours available until 9/25/19.
Requirements for Successful Completion:
Complete the learning activity in its entirety and complete the online CNE evaluation. You will be able to print your CNE certificate at any time after you complete the evaluation.
Conferences Committee Disclosures:
- Elizabeth St. John – Employee, Fresenius Kidney Care
- Marijo Johnson - Employee, Fresenius Medical Care
Speakers Conflict of Interest Disclosure: There are no other disclosures to declare.
Commercial Support and Sponsorship:
No commercial support or sponsorship declared.
American Nephrology Nurses Association – Provider is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.
Nephrology nurses will articulate the ethical issues surrounding medical errors and describe the use of medical apology statutes.
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Why have health care workers felt the need to avoid disclosing errors that are made? Fear of retribution, punishment Is this more or less true today than when you first entered the profession? I would say the same and I have been an RN for 37 years. There is more awareness and better processes but I think the human emotions involved are the same. What type of legal issues have you noted, either from being reported in the media, or in your discussions with other healthcare professionals, as occurring more frequently now than they were in the past? We have created a society that is eager to sue individuals. Patients will even tell us upon admission they are watching us closely and will sue us if they think we deserve it. That does not create a environment of mutual trust and makes nurses and staff avoid the patient altogether as much as possible. What was the most interesting thing you learned from listening to this session? The principle of deviation from the standard. I see it so much in dialysis. I am amazed at how many different ways new nurses are taught to do things that should not be different. The standard should be taught, not a particular nurses idea of how the standard should look like.
I agree with Barbara the fear of retribution, punishment are reasons that healthcare workers avoid disclosing errors. Beth also talked about a kind of inertia that seems to make us not report mistakes, or even near misses. Sometimes, it was mentioned , we are so busy that we just correct the error and never go back to report it. More awareness due to social media. It seems that we are bombarded with "reporting of errors, issues, etc. all day. I am not sure if errors are happening more, or are they just reported more? Interesting that each state has its' own "Error reporting Law"... I thought this was pretty standard across the board. I loved the Vision for Transformation where "every worker is empowered to prevent system breakdowns & correct them when they occur"...it ties right into Florence Nightingale's how can I provide for this right thing to always be done. Each of us (not just management, "leadership"... ) If we are truly able to accept responsibility for the right thing always being done, we can accomplish that culture of safety. I thought this session was very informative and interesting.
There is a problem with health care workers fear of disclosing errors because they are afraid of work retribution and admitting they made a mistake. This has changed a lot some since I became a nurse. I have been a nurse for over 20 years. When I first became a nurse, I do not remember anyone discussing near misses or reporting mistakes. I am now encouraged at my workplace to do both without the blame game. I think the media today overemphasizes bad care and does not show the wonderful care being given by many. I think the bad care shown in the media does encourage accountability but it also causes the patients to distrust caregivers. I have found in outpatient Dialysis this is often overcome by the patient’s ability to know and trust staff over time. The speaker in this CE was very interesting and brought out the fact that managers can make a big difference in decreasing mistakes by encouraging openness of staff mistakes. This is really the best way to fix the systems of care. She also mentioned that sometimes the protocol of how something is done is not what is being actually done by the time it’s been taught to several people down the line so it’s important to be aware of what is actually being done as “protocol” before changes are made.
Excellent, very informative
I became an RN 12 years ago. I was taught the concept of "just culture" and the importance of reporting near misses even 12 years ago. Healthcare organizations are doing a better job today of addressing medical errors, but the written polices of reporting remain vague and unclear. In my opinon, the stigma and shame of medical errors remain the same as they have always been. Many times nurses are just trying to survive their shift with the least amount of drama as possible. Reporting the near miss or appropriately dealing with the aftermath of an error takes time. With unreasonable current RN workloads, its easier to continue to minimize or ignore near misses and to move on as quickly and quietly as possible from an error. It is also possible that unsafe situations and near misses were reported and ignored enough times that some nurses cease reporting. Discussions surrounding medical errors seem to be occuring more frequently in the conventional media as well as social media. Some patients know they will never get validation from the health care facility where they had a bad experience so they seek that validation from social media peers. I learned several interesting things in this presentation, but the information regarding apology laws was the most beneficial. My state law could be the reason my facility policy is vague. I will have to look at both a little closer.
Great presentation. A little long but well worth it.
I loved this module. So much information that I did not know. Plus makes me want t even be more careful so as to avoid errors in the first place. Now I want to get my chapter involved in this CEU. Thanks so much!