“Just Culture” and human error

If you’ve watched the News lately, you know that there is a (former) nurse in Nashville, Tennessee who was found guilty of negligent homicide due to a fatal medication error that killed a 75 year old man. For those of you that are not familiar with the medications cited for causing the error, she gave Vecuronium (a paralyzing agent used to chemically “paralyze” a patient, often given for a need to intubate someone, or to keep them from not moving as a skeletal muscle relaxer); Versed is a sedative. Other than starting with the letter “V”, they should never be confused. Never. Ever. Both of these are high-alert medications that should require a 2 RN verification process prior to administration. Vecuronium, in fact, is most often only administered by a physician, usually an anesthesiologist or nurse anesthetist. What this nurse was thinking when she pulled it out of the Pyxis, and confused it with Versed, one can only guess. Safety processes that are implemented to prevent errors like this from occurring, were ignored (and overridden), and as a result, tragically, a man died. I am sure that it is something that she profoundly regrets, and will never forgive herself (for). My heart really does sympathize with her.

Clearly she made a huge, unsafe error that cost her (her) professional nursing license, but should she go to jail as a criminal, is the controversial question? Some of my friends and colleagues have very strong feelings and opinions on both sides of that final judgement. Mine lies somewhere in between, as it often does when you deeply understand the root cause of what could have caused the event, because as a nurse, I know that accidents/mistakes/errors often happen due to a bigger picture of organizations failing to maintain safety protocols. While I do not know the entire story of what happened that day to make this nurse choose this medication, my understanding is that the “system” in which this nurse practiced failed her, and they too, are at fault.

A “Just” culture considers errors an opportunity for learning, to improve outcomes and performance, as part of their Quality Improvement measures; they acknowledge that errors happen due to faulty organizational cultures, rather than placing blame, or initiating punitive measures, solely on one individual (Wikipedia, 2022). Supporting the Just Culture approach to promoting safety and quality in healthcare means to seek out why an error occurred, rather than pointing fingers (or throwing someone under the bus as a scapegoat), by identifying “how” it happened, to improve practice, and prevent it from happening again (Boysen, 2013). Nevertheless, having a Just Culture cannot be a blame-free environment that does not demand accountability for errors. Was this a properly trained, competent nurse? I cannot say, but from what I have heard, she was transparent with admitting the error, and said that she was “distracted” and “complacent” (Kelman, 2022). As nurses, we can never allow ourselves to practice in such a mindset; we will always set ourselves up for errors.

References:

Boysen, P.G. (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner Journal. Retrieved from https://ncbi.nlm.nih.gov

Kelman, B. (2022). Former nurse found guilty of accidental death of a 75-year-old patient. Retrieved from https://npr.org

Wikipedia. (2022). Just culture. Retrieved from https://en.m.wikipedia.org

Anxiety

Experiencing anxiety is scary. I’ve rarely had feelings of being so restless or nervous that my heart could actually explode in my chest, but I have been feeling anxious a lot lately, and it is unsettling. I don’t know if it’s because I have had so many changes this past year, or the culmination of the last few years, but here I am… going through “stuff” that makes me feel very uncomfortable.

I also know that I have been feeling anxious for the brave and resilient people of Ukraine as a result of this horrific invasion by Russia… watching these families be separated, with women, children, and the elderly fleeing from their beloved country, to escape to Poland without knowing anyone there, or how they will survive, and having to say good-bye to their husbands/fathers, who must stay to defend their country… it is devastating, and it is hard to watch. But it is hard not to watch also. We are all brothers and sisters on this Earth, and the human connection can be just as strong as if we, too, were Ukrainian. It is the “what ifs…” that can be hard to think about as we try to predict the outcome of this pure evil and devastating act of aggression from a madman.

Part of my coping mechanism to process and manage my many thoughts is to write them down, so I will try to focus on things that I can actually control.

Some things that I have found helpful when I am feeling anxious.

I recognize that part of my anxiety is because I am at a crossroads with my job, and feeling alone and isolated. Life is too short to spend in a job that you do not love doing. You cannot just “go through the motions” when you work in healthcare, you just can’t. You won’t be successful, and even more importantly, you won’t be happy. I’ve been debating about the pros and cons of “staying in my lane” when it comes to career choices, and it has been a frustrating thing for me because I have always advocated for nurses to expand their horizons and see what opportunities come up that can challenge them in new ways. Change is good, yes? But what if it’s not? What if you choose a path that doesn’t feel right and doesn’t really “fit” who you are, or who you want to be… at the age of 55, where I am closer to the ultimate goal of a comfortable retirement.

I LOVE nursing. I love the feeling of being of service to others, and feeling like I am successfully fulfilling my God-given purpose. I also love working with nurses; standing beside them, and helping in any capacity that I can. I know that a job does not define who I am, but my career, and my passion for nursing DOES define me. I have spent more than half of my life being a nurse, and it has always “filled my cup” with a lifetime of fulfilling and rewarding memories.

I always thought that working from home was the ultimate “work place”; while I do love being in my new home, with my two “golden girls” (my faithful furry companions, Sammie & Gracie), it can also be very isolating, and that does not help my anxiety. It is hard enough to learn a new role when you are in an unfamiliar environment, but it is even harder to do virtually. I don’t run away from a challenge, or things that are hard… God only knows that I have had hard times and struggles in my life… but I think that may be the problem. I don’t like to (just) give up. While I do have hope that some things with my job are improving, but in reality, the things that I, personally, struggle with (like actually feeling confident, competent, and valued for my opinions, experiences, and instincts), will most likely, not.

This is easier said, than done.

I had a bad day…

Some days are just too damn hard. It always makes me question “how the hell did I get myself into this mess… I should know how to avoid conflict by now”. I really do try to not take these things personally. I understand that it’s not about me … it’s usually about things that are way beyond my control… and isn’t “control”, or loss of it, the problem? Loss of control makes people angry… sometimes really angry… and (some) people can lash out against whomever they see standing in their way of what they want, or need. I know this to be true, but it still sucks to be at the receiving end of misplaced anger and aggression. In a world where many of us are trying to lay low, and avoid people who could potentially “turn” dangerous, it’s important to know when to ask for help from our employers to support us, and ensure that we are not being mistreated by those whom we are (only) trying to help.

It is so hard to work in healthcare, especially now during the extended period of Covid and its multiple variants. Most of us are working short-staffed, and many nurses are quitting the profession entirely. I know nurses who read my blog are all too familiar with the struggle, but for those who need to hear this… you can’t control what people say, do, think, or believe, you can only control how you respond to it. That’s it. So while I try to “shake it off” so I don’t lose sleep over what I should have said… I will know in my heart that I am not the only one having a bad day too.

Yes, it is my pleasure to recommend you for this job!

Never underestimate the importance of experiencing the best and worst days in your nursing career with friends and colleagues who have walked those long hospital hallways right beside you. I always knew the reason behind my success, and decision to keep showing up when things got hard, was because of the special bond that we all shared with one another. Yes, it is always about our patients, but it is also about not dropping the ball when our team needs us.

I think this is what I miss the most. I miss the camaraderie and the connections. I miss feeling like I am a small part of a much bigger picture. I miss laughing when the only other emotional choice would be to cry. I yearn for the days where I wouldn’t have to look more than a few feet away for a friendly face who was willing to share a not-so-fun task with me, if for nothing else than moral support or a witness! I miss those days, but I will never forget them for as long as I live.

I often get asked to provide professional recommendations for many of the nurses that I have worked with in past roles as either a peer or manager. I see it as an honor that I am entrusted with this important step in creating new and exciting career opportunities for the people who continue to challenge themselves to learn and grow, for only change can provide new perspectives and ideas to help us to think and practice in a different way from what we already know. Today, as I completed one of those professional references for an old friend, I thoughtfully considered the last question, “What are the top 3 strengths of this candidate?”. All I could think of is “where do I begin…”. As a nurse who showed up to care for the sickest of the sick in 2020, in NYC, during the earliest, scariest, and deadliest time of Covid, the “strengths of a nurse” have new definitions, like courage and bravery, selflessness, and unparallelled dedication to her (or his) patients. In a time when the future was not certain, and science became so unpredictable, even deadly, showing up day after day, is really all that needs to be said. That’s the nurse who I want working beside me, whether we are in a pandemic or not!

Remembering my purpose

I was just honored with an award for my blog. I never expected it, and it was a joyful surprise, and I haven’t had many of those lately. It’s never been a competition for me. It’s just been me, sitting at my laptop, and writing what is in my heart. Less of an ambition, than it was a form of self-expression. I prefer my words in the written format, because I am less astute at the speaking part of interactive communication. This recognition was a gift I think that I needed right now, with feeling somewhat uninspired as of late. So I am grateful for the kind words. It made me very happy and proud.

Being a nurse has been the one thing that I have been really good at; it’s how I define myself, even now. But I was having lunch with friends recently (all nurses) and we started talking about our most memorable experiences and patients… and we had some serious belly laughs… and some painful memories came up as well. It made me remember something that I heard that goes a little like this… “you pay for good days by having bad days, you pay for joy with pain”. And it was then that I realized that I almost forgot “her” name. I remember everything about her, from the day of her cancer diagnosis, to her last day on this earth in the PICU many years ago. As fate would have it, I was there for both. But I never want to forget her name. She was important and she was memorable… and she made a difference to all whom she met in her too-short life. She has always been one of my “reasons” for being proud of what I do for a living.

I have the heart of an empath; I can feel sadness and pain, and it makes me feel the same. I can feel joy and lightness, and it makes me feel alive. I am the happiest when I feel like I am doing something to help others, so when I feel like I am in a rut, I feel useless. And that is not a great feeling.

I currently work as a nurse for an insurance company; it’s a good job and I get to mostly work from home, which is a huge part of why I made this career choice. But as a nurse, it’s never been about insurance…never. Insurance is boring, let’s face it. Being a nurse is far from that. I can tell you that we never even considered it in our practice. That’s not to say that it wasn’t an “issue” in the medical management of our patients, just not “our” issue. I believe that we all deserve the same level of great care. Period. Hard stop.

That’s why it’s so hard for me to understand when my “members” (my pediatric patients) don’t get approved for important procedures/testing/consults with specialists that are out-of-network, etc., that could help with diagnosing, or managing, complicated medical and behavioral problems. I come from a place that always wants to help; to fix what is broken, but I can’t do that now. It’s not the way that this job works. But they try, and I try. And that’s important too. I guess I just need to remember my purpose in all that I do, whether I can see the outcome of that, or not.

The stress of change

I’ve spent a lot of time feeling (very) comfortable in my role as a clinical Nurse/Supervisor for more than 30 years. I got to the point in my career where it felt like “home”, walking through the hospital, with cardiac monitors alarming and call bells ringing, and the hustle and bustle of nurses and clinical staff running into patient rooms responding to help. It’s a well-earned level of expertise that gives one a feeling of confidence that strengthens your spirit, and puts you in a state of catlike readiness to handle the unexpected crisis’ that occur when you least expect it. It’s what I know, and what I love; it’s my life… well, it was my life.

But now everything has changed, and I can’t remember when I’ve ever felt this stressed-out. Between a recent surgery, selling my house in the state where I was born and raised, building a new house in a different state, and changing jobs, sometimes I don’t know where to start on my colossal list of “things-to-do”. It’s overwhelming, and I just want to press “pause” on this big, blue marble called Earth, and basically just take a long nap. My confidence level at work is at an all-time low. My new job is so different from what I have known, it challenges me in ways that I never anticipated. Being challenged is not a bad thing, but it makes me feel very uncomfortable being so inexperienced, and dare I say, “stupid”? It’s a feeling of complete vulnerability, which is the absolute worst, at least it is for me.

We all make life and career choices every day; for better or worse, and sometimes, with just a leap of faith that it’s the right thing to do. What we don’t see when we are making these difficult choices, is the future outcome. I guess that’s what is so exciting. It’s a new beginning, and sometimes the hardest things in life turn out to be the most rewarding.

It’s so hard to say good-bye to yesterday (Boyz ll Men)

I left a really great job yesterday, where I worked with really great people… extraordinary, really. We all work really hard, with our own unique contributions (big and small), to get “our kids” strong(er)… to heal all that can be healed, to the best of our ability… and hopefully, we get to send them home to their grateful families, to carry on with their lives, and experience the gift of growing up. I will miss this special place, and all whom I was lucky enough to meet along the way. I gained so much from you Children’s Specialized Hospital, but best of all, I gained many cherished friends.

Friends make everything better… even when you’re working short-staffed, and have really bad days! I’ve worked with my great friend, Nicole, for over 21 years… we’ve seen it all, and have countless stories to tell about each other… and everyone else! She has been my one constant in every job since the year 2000. She made me a better nurse, and a better person. No matter what, she always sees the silver lining, and works tirelessly to lead by example. I will miss her the most.

It’s so hard to say good-bye. I am terrible at it. I am a cryer, so there is always an abundance of tears, and a red, runny nose, that requires fist-fulls of tissues to soak up the mess. How lucky am I that I got to work with such wonderful people, that it hurts so much to say good-bye to them?

Thank you to my friends at CSH for the beautiful flowers, balloons, and card. I love them… you are all very special to me.

On Monday, I will start a new job, with an old friend (Hi Aileen!), and I will be able to use everything that I’ve learned, in my 30+ years of nursing, to be able to advocate for the underserved, and medically-fragile, pediatric population in my (new) county, in my (new) state, of Delaware. I have spent my entire career committed to caring for children, and this new role that I have accepted will help me to take my expertise one step further, and meet the families where they live, to better assist them in getting the medical help that they need to live a healthy life, and hopefully overcome some obstacles that they may have. 

Wish me luck!

It’s so Hard to Say Good-bye to Yesterday” (Boyz II Men)

… How do I say goodbye to what we had?
The good times that made us laugh
Outweigh the bad… I thought we’d get to see forever
But forever’s gone away
It’s so hard to say goodbye to yesterday… I don’t know where this road
Is going to lead
All I know is where we’ve been
And what we’ve been through… And if we get to see tomorrow
I hope it’s worth all the wait
It’s hard to say goodbye to yesterday… And I’ll take with me the memories
To be my sunshine after the rain
It’s so hard to say goodbye to yesterday… And I’ll take with me the memories
To be my sunshine after the rain
It’s so hard to say goodbye to yesterday

Source: LyricFind

Songwriters: Christine Yarian Perren / Frederick PerrenIt’s So Hard to Say Goodbye to Yesterday lyrics © Sony/ATV Music Publishing LLC

Mental Health: hope & light vs. darkness

I’ve watched the movie “Soul” so many times, and these words always break my heart:

You can’t crush a soul here, that’s what life is for.”

(22 to Joe Gardner in “Heaven”, Soul)

Life is hard, it can (literally) be soul-crushing. It can be painfully cruel, and it is definitely not always “fair”. I try to remember that there are more “good” people in the world than bad, and most people mean well, but we live in a world where half of Americans can’t agree on basic truths. There is so much division and inequality that it is difficult to stay positive and not be pulled into a dark and negative space. At the end of the day, when we are left with our own thoughts and little distraction, we can feel alone and vulnerable, and feelings of loneliness, sadness, or regret can crush one’s soul.

But what if those dark thoughts are not yours; they are the thoughts of someone you love, and worry about every single day… what if every time the phone rings, you worry that you will hear the panic, or rage, or sadness in their voice… you stop breathing and your heart sinks, and mentally you go back to “that” day last year when you discovered that your child didn’t want to live anymore; she was depressed and in such a dark place that she could not see that things could get better. It hurts so much to see your child in pain. When you are a mother, it doesn’t matter how old your child is… 8 years old or 28… the worrying never stops. So you pray, and you hope that today is a good day.

2020: the year of loss

2020: the year of loss

2020 was an unforgettable year that changed all of our lives, one way or another. As a nurse, my role was to show up and do my job, no matter what. We serve and care for others during a crisis… be it a pandemic, a destructive storm, or any other emergency that involves “essential workers” being placed in potentially dangerous conditions. Many healthcare workers have been traumatized by what they witnessed every single day during Covid. They were very brave; they felt the fear of the unknown, and they showed up anyway, in spite of it. They cared for the ill, and provided compassion and a hand to hold for those who passed. Covid changed all of us, for better or worse. Those images do not leave your head and can haunt you if you can’t separate work from your “real” life. For me, (just) being able to go into work and focus on others, gives me an opportunity to put my own “stuff” into perspective. After all, we get to go home at the end of our shift, our patients do not.

Mental Health Awareness

Please remember, as we say good-bye to May, which is Mental Health Awareness month, we need to continue to shine a light on the darkness and stigma of mental health, regardless of the month. The day-to-day struggles live on in so many of us. We all have things that we carry with us, and we all go through personal struggles; however, not everyone has the tools in their virtual mental health tool box to manage the rough waters that can pull us under, without a life preserver to keep our head above the water, and save us from drowning.

When one has mental health issues, they have to be brave (enough) to ask for help. But many cannot find the words to say it out loud for someone to hear (and help). This invisible illness is usually hidden and not talked about… often, until it’s too late. If only they held onto hope a little bit longer.

“Hope” is such a big word to me. It means so much more than the words that define it. It is everything. It is the past, present, and future. It is all of what you want things to be, and all that can be… it is the feeling that can keep someone holding on, and not giving up, despite being afraid.

The most important thing to remember is that you are not alone. There is always at least one person who cares about you. There is always hope.

If you, or someone you know, is struggling, please remember that there are places to go to for help, and people who can support you:

Call 1-800-273-TALK (8255) to reach a 24-hour crisis center, text MHA to 741741, call 911, or go to the nearest emergency room.

The Kindness of Others… and by Others, I Mean Nurses

Life is hard; sometimes it can become very overwhelming, and can lead one to a feeling of indifference towards others. We focus so much on our own “stuff”, that we can’t see past it, to recognize when others may be struggling as well. Even those closest to us may not know the many burdens that we carry, because we hide it well, and often suffer in silence. 

This past year in particular, was relentless with tremendous loss, isolation, fear, and anxiety. It was the “perfect storm” for those who usually seek relief from stress by socializing with friends and family. Many of us lost that. I lost that.

We lost hugs. I am a “hugger” and I really missed hugging my friends! We even lost our smiles; they had to be hidden by a facemask at all times to protect us from a deadly virus. But smiles are so important to connect with others! We had to rely on our eyes to communicate our feelings, and that is not always easy to do. And we made mad dashes to the grocery store, dripping in hand sanitizer, hoping that no one around us dare clear their throat with a cough. (God forbid)!

But this is where I start bragging about Nurses. It’s Nurse’s Week, and this year we all deserve a damn vacation! We went to work every day to take care of our patients, just like always, as if there wasn’t a global pandemic that kept many others home from work or school. Our “business” never closed its doors. 

According to Psychology Today (2021), altruism is helping others at some cost to ourselves. It is showing empathy, and purposefully acting in a selfless way to help others. Nurses are the definition of altruistic! During this pandemic, nurses gowned up Every. Single. Day. They wore restrictive and uncomfortable PPE for 13+ hours until their faces were bruised. They washed their hands and uniforms as if hoping they could be sterilized, so as not to pass the virus onto ourselves, or others. Nurses kicked ass this past year, but there was a high cost to be paid. Too many lost their lives in this battle, and on this week of celebrating nurses, please take a moment to remember them, and their families, in our prayers. They were brave and kind and altruistic… and they paid the ultimate sacrifice in this Covid war.

Please take care of yourselves this week, you deserve it! Thank you for your kindness, love, and friendship; thank you for being you!

Happy Nurse’s Week!

Reference:Psychology Today. (2021).  Retrieved from https://www.psychologytoday.com

Birthday Girl

Today is my Birthday! (yay!) It’s not exactly a big milestone, more like a half of one, but the number does frighten me a bit. Honestly, I should get a “do-over” because 2020 was such a dud.

As I reflect on these fifty-five years (holy crap-oly!) that God has given to me, I see an abundant view that is a privilege denied to many. I have much to be grateful for, and I try to remember that, even through the bad days. 

Life, in general, can be complicated… it’s a day-to-day rollercoaster ride of ups and downs, until it’s over… which is something that I’ve actually been thinking about a lot lately; maybe it’s my age, or this past year of such devastating loss due to Covid… and the isolation, of course. The isolation has been really hard. Fortunately, I’ve had so many wonderful friends in my work “pod”, at least that part of my life hasn’t been lonely. Nurses are essential after all, not to mention, “superheroes”!

But I’ve gotten stronger and bolder as I’ve aged; I think that’s how it’s supposed to be. You become less worried about what others think (of you), and focus more on the important things, like being true to oneself. 

I (almost) always say what goes through this busy mind, for better or for worse. That’s why I write in this blog; it may seem silly to some, but it helps me to just sit still and thoughtfully think about what I want to say. It can be very scary to open up and share yourself with others, mostly because people can be so judgmental, but experience has given me confidence, and a feeling of self-worth and courage, that I didn’t have when I was younger.

Thank you for letting me into your lives, listening to me, showing me love and kindness, and laughing with me, and not at me.

Today is my birthday! I will celebrate life, and all that it has given to me, as I imperfectly live it, one day at a time.