Chasing Zero Summary

On of the many issues that was brought up in the “Chasing Zero” video was harsh punishments for health care professionals who make mistakes. The reason I choose this particular issue is because I believe it plays a key role in all health care errors. Every single health care error that is made is a learning opportunity. Taking an error and doing something constructive with it can lead to incredible improvements in patient safety. When this is not utilized, patients and health care professionals are penalized. An example of this is demonstrated by the tragic story of a nurse, Julie Thao, who accidentally connected the wrong medication to her patient’s IV. Unfortunately, her young patient died from the error she made. Rather than investigate …show more content…
First, the patient lost her life as a result of an avoidable error. Second, a competent nurse lost her license and was fired for her human error. Nothing was done by the hospital to try and learn form this mistake. Rather than investigate the factors that caused the event, such as over worked nurses and similar labels on drugs, the hospital placed blame on the nurse in order to try to avoid expensive lawsuits. Listening to Thao’s story made me fearful as a future nurse. We have put so much time and money into becoming nurses and one simple error could end it all. Julie Thao could have faced jail time for her mistake and it is terrifying to think that so much blame is being placed on individual health care workers and not the flawed …show more content…
The LNP I was shadowing wanted me to prepare the medications for a patient while she gave her other patients their scheduled medications. I was preparing my clients medication at the med cart and beside me the LNP was preparing her clients medication. I had placed my client’s medication in a little cup as I pulled them out of their containers. As I was grabbing another medication for my patient, the LNP grabbed my patient’s medication cup thinking it was hers and started to walk away with it. When I looked back up and saw my patient’s cup was gone I quickly realized what had happened and stopped her from giving it to her patient. There were many factors that contributed to that near miss. The LNP was working too fast in order to try and keep up with the two halls of patients she was assigned to treat that day because the facility was under staffed. She was rushed and pressed for time so rather than wait for me to finish getting the medications I needed, she started to pull them right beside me. Thankfully we were able to identify the error before it harmed our patient. In that moment I realized just how easy it is to make a medication error. In order to avoid an incident like this from happening again, another staff member should be employed to help eliminate some of the burden that is placed on the LNP and decrease the number of patients she has to care for in a short period of time. If