You are the unit supervisor of a medical-surgical unit.  Jane is an RN on your unit.  She graduated 3 years ago from nursing school and has made a number of small errors in the past few months, all of which she voluntarily reported.  These errors included things like missing medications, giving medications late, and on one occasion, giving medications to the wrong patient  No apparent harm has occurred to her patients as a result of these errors and on each occasion, Jane has responded to your coaching efforts with an assertion that she will be more attentive and careful in the future.  Today however, Jane came to your office to admitted that she flushed a patient’s iV line with 10,000 units of heparin rather than with the 100 units that was ordered.  The vials looked similar and she failed to notice the dosing on the label.  Jane reported the error to the patient’s physician and filled out the adverse incident report form required by the hospital on all medication errors.  At this point, the patient is demonstrating no ill effects from the overdosing but will need to be closely monitored for the next 24 hours. You recognize that Jane’s pattern of repetitive medication errors is placing patients at risk.  You have some reservations about dealing with Jane in a punitive way since she openly reports the errors she makes and because none of her errors until today ad really jeopardized patient safety.  You are also aware that you have an obligation to make sure that the staff caring for your patients are competent and that patients are protected from harm.  You are also attempting to establish a unit culture that encourages open reporting, not “shame and blame” so you are aware that your staff are watching closely how you will respond to yet another error on Jane’s part. Please answer the following questions on how you would handle the situation (5 points each) #1.  What will you do to address this error as well as the errors Jane has made in the past few months? #2.  What options are available to you? #3.  What obligations do you have to Jane, to the organization, and to the patients on your unit? #4.  How will you create a culture that encourages the open reporting of errors and yet protects patients from potentially unsafe practitioners?

1. To address this error as well as the errors Jane has made in the past few months, I would take a proactive and comprehensive approach. Firstly, I would schedule a private meeting with Jane to discuss the recent medication error and express my concern about the recurring pattern of errors. This conversation will provide an opportunity to gain insight into Jane’s understanding of the situation and her willingness to improve her practice. I would emphasize the importance of patient safety and the potential consequences of medication errors.

Next, I would provide Jane with additional education and training on medication administration, emphasizing the importance of double-checking medication labels and using appropriate safeguards to prevent errors. This could include reviewing medication administration protocols, participating in medication safety workshops, or shadowing experienced nurses to observe best practices.

Furthermore, I would implement a system for ongoing monitoring and evaluation of Jane’s medication administration skills. This could involve periodic observations of her practice by a more experienced nurse, reviewing medication administration records, and conducting regular performance evaluations. By closely monitoring Jane’s progress and providing constructive feedback, we can proactively address any recurring issues and support her in improving her practice.

2. Several options are available to address the situation. One option is to implement a performance improvement plan (PIP) for Jane. A PIP would outline specific goals and expectations for her to improve her medication administration skills. It would include regular meetings to assess progress and provide support, as well as consequences if improvement is not achieved within a specified timeframe. This option would provide a structured approach to address Jane’s performance concerns.

Another option is to provide Jane with additional mentorship and coaching. This could involve pairing her with a more experienced nurse who can provide guidance and support. Regular check-ins and debriefing sessions with the mentor can help Jane reflect on her practice, identify areas for improvement, and develop strategies to prevent future errors.

Lastly, if the errors persist despite interventions, it may be necessary to consider reassignment to a different unit or role that does not involve direct patient care with high-risk medications. This option should be considered as a last resort, as it is important to exhaust all possible interventions before making significant changes to an employee’s responsibilities.

3. As the unit supervisor, I have obligations to Jane, the organization, and the patients on the unit.

To Jane, I have an obligation to support her professional growth and development. This includes providing educational opportunities, coaching, and mentoring to improve her practice. I also have a responsibility to ensure Jane’s safety and well-being by addressing any underlying factors that may be contributing to her errors, such as high workload or inadequate resources.

To the organization, I have an obligation to maintain high standards of patient safety and quality care. This includes identifying and addressing any performance concerns that may compromise patient well-being. Additionally, I have a responsibility to uphold the organization’s policies and procedures, including reporting adverse incidents and implementing appropriate corrective actions.

To the patients on the unit, I have an obligation to provide them with competent and safe care. This involves closely monitoring medication administration practices and ensuring that any identified issues are promptly addressed. I also have a responsibility to communicate openly and honestly with patients and their families about any errors that may have occurred, providing reassurance and necessary follow-up care.

4. Creating a culture that encourages open reporting of errors while protecting patients from potentially unsafe practitioners requires a multifaceted approach. Firstly, it is essential to foster an environment of psychological safety, where staff feel comfortable reporting errors without fear of retribution or judgment. This can be achieved by promoting a blame-free culture, where the focus is on learning from errors rather than assigning blame.

Additionally, robust systems should be in place to capture and analyze medication errors. This includes implementing incident reporting systems and conducting thorough investigations to understand the root causes of errors. By sharing these findings with staff, opportunities for learning and improvement can be identified.

Training and education on error prevention should be a priority, ensuring that staff are equipped with the knowledge and skills needed to prevent errors. This includes promoting effective communication and teamwork, encouraging double-checking procedures, and providing ongoing education on medication safety.

Regular forums for staff to discuss errors and near-misses can also be beneficial in creating a culture of open reporting. Opportunities for reflective practice and case reviews can help identify system weaknesses and individual learning needs.

Finally, it is crucial to lead by example. As the unit supervisor, I would actively demonstrate openness and transparency in discussing errors, acknowledging the importance of reporting, and showcasing a commitment to continuous improvement. This can help build trust and confidence among staff, encouraging them to come forward with their own errors and concerns.

In conclusion, addressing Jane’s recent medication error and the recurring pattern of errors requires a proactive and comprehensive approach that includes education, training, ongoing monitoring, and a focus on creating a culture of open reporting. By balancing the obligation to support Jane’s professional growth with the responsibility to ensure patient safety, it is possible to address the situation effectively while promoting a safe and learning-based environment.