'Culture change' required in how nurse drug error is managed

Howard Catton, CEO of the International Council of Nurses, is using this year’s World Patient Safety Day to highlight the theme of ‘drug safety’ to help health care providers address drug malpractice cases involving nurses. called for a change in the way we manage

“What is needed is a shift from criminalizing and disciplinary thinking to educational communication and dialogue.”

Howard Catton

He stressed that nurses have a “grave responsibility” in this area, but that the negative effects of over-expansion of services and worsening staff shortages should not be ignored.

Led by the World Health Organization on September 17 each year, the annual Awareness Day brings together patients, families, caregivers, communities, healthcare professionals, leaders and policy makers to unite our commitment to patient safety. indicate.

This year’s focus is on drug safety, with the slogan “medicine without harm”.

According to WHO, the campaign will raise global awareness of the “high burden of medication-related harm from medication errors and unsafe practices” and “advocate urgent action to improve medication safety”. It is intended for

International bodies have stated that drug errors are due to “systemic problems and/or human factors such as fatigue, poor environmental conditions, or staff shortages that affect prescribing, transcription, dispensing, administration, and monitoring practices.” I knew it would happen.

It added that there was evidence to suggest that “more than half of all phytotoxicity occurs when the drug is prescribed and when the patient is taking it due to inadequate monitoring.”

Antibiotics were the “highest risk” category of medication-related harm, according to the WHO, but added that drugs such as sedatives, anti-inflammatory drugs and heart and blood pressure medications also “pose significant risks”. .

WHO Director-General Dr Tedros Adhanom Ghebreyesus said: “Pharmaceuticals are powerful tools to protect health.

“But medicines that are misprescribed, mistaken, or of poor quality can cause serious harm. No one should be harmed while seeking care.”

ICN welcomed this year’s focus on medication, but also called for a change in the culture of how nurses manage and address drug errors.

Speaking at a WHO virtual event ahead of Awareness Day, Catton described the “current blaming culture around nurse malpractice” as “the enemy of patient safety.”

“I’m not talking gross negligence, but honest mistakes often lead to system failures in organizations,” he said.

“We are not trying to absolve nurses of responsibility, but when errors do occur, open reporting can lead to learning, not only for the individuals involved, but also for the organizations they work for.”

“It’s important to have a ‘fair culture’ rather than imposing immediate sanctions, referring nurses to national nursing regulators and disciplinary action,” Catton said. did.

“What is needed is a shift from criminalizing and disciplinary mindsets to communication and dialogue that leads to learning, improvement and significantly improved patient safety,” he added.

The ICN CEO highlighted the recent case of US nurse RaDonda Vaught. He committed a fatal drug error and was charged “despite evidence of system failure.”

He went on to warn of the negative impact strained health services and nurse shortages have on patient safety.

“Nurses have a significant responsibility in administering medicines, but they often find themselves working in environments that are overstretched, understaffed, and too busy to consistently provide the quality care they desire. We know.” Catton.

“We know that all these factors can lead to errors, including potentially serious medication errors.

“We cannot ignore the fact that the world is short of millions of nurses, perhaps as many as 13 million. We cannot ignore the fact that we are giving.

“And of course medication safety is an example of an error that can have very serious consequences for a patient’s health.”

The UK’s NHS was recently exposed to a record shortfall of nearly 47,000 nurses.

Also ahead of World Patient Safety Day, Patricia Marquis, UK Director of the Royal College of Nursing, expressed concern that nurse shortages will affect patient care and medication safety.

“Keeping patients safe is at the heart of everything nurses and nursing support workers do, and this year’s theme, Medication Safety, is about just that,” said Ms Marquis.

“But with one-eighth of nursing positions vacant in the UK and similar in other parts of the UK, the workforce crisis means that care is not being delivered and patients are at risk. I mean

“When staff are overburdened and unable to give patients proper attention, medication errors are much more likely to occur.”

She added:

“The best way to improve patient safety is to have the right number of staff on shifts.”