Nursing

Medical Errors: What a nurse knows about protecting patients

Nurse Leader Insider, July 14, 2016

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Written by Jennifer Thew, RN, for HealthLeaders Media.

We've all heard harrowing stories about medical errors.

They are the third leading cause of death in the U.S., estimated to be responsible for more than 250,000 deaths per year.

Donna Helen Crisp, JD, MSN, RN, PMHCNS-BC, knows about medical errors firsthand. She has experienced more than one and has lived to write about them.

Crisp's story, or "debacle," as she describes it, began in 2007. After undergoing a laparoscopic hysterectomy for uterine cancer, medical errors left her fighting for her life on a ventilator in the surgical intensive care unit.

Pressure from the two surgical graspers applied by the surgeons left Crisp with a perforated small intestine that was undiagnosed for more than 36 hours.

Her severe post-op abdominal pain, a tell-tale sign of a perforated bowel, was instead chalked up to gas pain. When she was finally taken for emergency surgery where, because of improper intubation technique, she aspirated the radiopaque contrast dye she drank for a CT scan.

As a result, she experienced acute respiratory distress syndrome, sepsis, more surgeries, and was on a ventilator in SICU for three weeks—of which she has no recollection.

"My memory stops in the little room where I changed my clothes," she told me.

It took Crisp years, with the help of a lawyer, to piece together what happened. The hospital and physicians offered very little in the way of explanations and no apology for what happened.

'Nurses Can Do So Much More'

I asked Crisp what she thinks nurses can do regarding medical errors. She slept on the question and the next day, emailed me her answer, which has been lightly edited:

"The power for changing the paradigm in hospitals involves hospital administrators and leaders, healthcare insurance companies, physicians, nurses, and the patient-consumers.
Nurses can do so much more, if they are capable of becoming empowered to truly put the patient first.  Even if nurses meet resistance, they can do more, if they try, than if they remain silent and therefore complicit in things that are wrong."

She encourages nurses at all levels to be vigilant, to ask questions, and to think critically.

"Let curiosity or confusion lead to knowledge, conversation, and professional growth," she advises. "Always ask why, and why not."

Lastly, she advocates for bravery and moral courage. Nurses should never be content to keep silent if they see something that could lead to an error or if they encounter a situation that caused an error. They must keep pressing others to help them do what's right for the patient.

"If you have to, pick up the hospital phone, dial "0," and ask to speak with the administrator on call," she says.

"Silence," she says, "creates further victimization."



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