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Dana Soulas Dr. Wells NUTH 101 26 April 2023 CHASING ZERO REFLECTION

For as long as I work in healthcare, I believe the documentary Chasing Zero will always be in my mind. This documentary focuses on medical errors and the detrimental effect that it can have on patients and their families. While it brings awareness to the harm that medical errors have, it also presents a goal: to continuously strive to decrease the number of medical errors to zero. Many people may think “zero” is an impossible goal to achieve, however if each person does their part the number zero is a realistic and achievable goal. The actor Dennis Quaid was the host of this documentary after experiencing a large medication error firsthand with his infant twins who were mistakenly overmedicated, which almost costed them their lives. Unfortunately, his story is not the only one to be shared within this documentary, as it also touches on Braxton Rel, Josie King, Cal Sheridan and Julie Thao, all individuals who fell victim to hospital system failure. As we listen to these different stories, it is apparent that multiple different safety practices and collaborative teamwork were not present. The six QSEN competencies are able to effectively reduce errors in the workplace when used correctly. The competencies include patient centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement (QI), safety and informatics. The first QSEN competency is patient centered care, where the goal is to provide adequate care that keeps patients informed and involved when it comes to decisions of their wellness. However, before a patient is able to make decisions about their health, they need to be educated. A patient who has personalized care, clear communication (which can improve compliance), honor their preferences, and reduce unnecessary procedures, are all first steps towards reducing errors. The next competency is teamwork and collaboration, which involves effectively communicating with other health care providers to ensure that their patient gets the best care. By having effective teamwork and collaboration errors can be reduced through listening to team

member concerns, preventing different interpretations and miscommunications, and failing to provide information to patients. As shown in the documentary, failed teamwork and collaboration could have contributed to the death of Mr. Sheridan. When Mr. Sheridan went in to get a tumor removed from his skull, a biopsy was sent to pathology. The report unfortunately never made it to his doctors. It was said that the report got filed in his chart without anyone seeing it, and it concluded that the tumor removed was cancerous. With collaborative communication via the pathology department and his doctors, this report would have never been hidden. Proper treatment, prevention, along with patient options which were never discussed or administered could have been life altering. Unfortunately, Mr. Sheridan died at Disney World. When all medical professionals of a health care team work together and effectively, safety and good quality of care is an achievable outcome. When you have team members conferring with each other, you will be more adapt to thoroughly understand the patients condition and problem at hand. Providers need to share decision making and use the different skill sets afforded to them to come up with the best care plan. Good communication may uncover different aspects which might be left out of a care plan, such as patient education, or a pathology report that gets filed away. Fostering strong nursing and interprofessional teamwork, optimal care is able to be handed off effectively and patient goals can be safely met. The third QSEN competency, Evidence Based Practice acknowledges using and applying current clinical expertise when delivering care. It is incumbent upon the nursing professional to always improve and continue their education about the most up to date technologies and protocols in order to apply them when practicing. Quality Improvement is the application of EBP to continuously improve the quality and safety of the care you are providing. As the field is always evolving, it is important to keep up to date with new EBP and implementation to make sure you are doing your best to prevent errors.

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For example, the documentary highlighted a group of medical students who came up with the “Check a Box, Save a Life” process, which is a combination of EBP and QI, that allowed for a list to always be checked off before a procedure was done. This provides standard care across procedures, proactive monitoring of the patient and the ability to make sure that nothing is being forgotten. Safety is one of the biggest concerns when it comes to health care. It focuses on both patient and provider safety through the use of the system and individual performance. Unfortunately, due to flaws in the system both patient and provider safety need a considerable improvement, as there are many inadequacies. Dennis Quade said “human error should not be criminalized; all it is going to do is alienate people that are trying to make things better” which is an important deficiency within the system (Chasing Zero). When a nurse makes an error, a large part of the time they will not come forward because they do not want to risk facing the consequences, which can be loss of their license and job. With better systems, as noted in Informatics, patient and provider safety will be increased, which will reduce the propensity to commit errors. Lastly, informatics is using information and technology to effectively manage patient care, prevent medical errors and improve communication. Through the implementation and use of electronic health records, barcode systems, medication pumps and automatic alerts, technology can manage to decrease multiple different areas of errors. While these systems do not critically think for the nurse, it is a system that makes sure the 7 rights match up correctly before administration. The QSEN competencies that I think are most important are safety and evidence-based practice. These are most critical when it comes to preventing errors because there is constant need to improve practice and implement the best procedures in both areas. The Caputi Method

uses the steps making meaning of the information, determining correct actions to take, and taking action, which are all critical steps when it comes to EBP and safety (Caputi). These three competencies are relevant as you have to find the most recent evidence, determine how you are going to implement the evidence into your practice, and then take action. I think after watching this documentary, taking action is the most important competency and the one I would like to embrace the most in my practice. I think it is easy to find the evidence and come up with how to implement something, but getting in the habit of safely administering something is the challenge. Medication error situations could have been reduced if they “structured the work environment to facilitate integration of new evidence into standards of practice” as well as “valuing their own role in preventing errors” (QSEN). When it comes to structuring the work environment better to incorporate new evidence, I think it is important to all employees that they are aware of new priorities, safety techniques or procedures. An individual needs to be aware of how they can prevent errors before they happen, whether it is limiting workplace distractions such as being on a cell phone while administering medications or realizing that they are fatigued. I think that fatigue and burnout is the greatest obstacle when it comes to implementation of safety in the workplace. When it comes to nurses, they are extremely overworked and understaffed when it comes to taking care of patients. If you are trying to implement more safety procedures it is important that the staff is well rested and able to adapt to new obstacles. For example, Julie Thao was a nurse that administered the wrong medication after working multiple shifts and then an extra shift. She mentioned that she was too tired to go home and come back, so she decided to sleep at the hospital. When she started her shift she had a patient that needed an epidural and antibiotic. Instead of administering the antibiotic in the IV, she administered the epidural, which caused her patient to go into cardiac arrest. Had Julie not been overworked, she would most likely been able to catch her error and follow the guidelines of checking the 7 rights

of administration. When an individual is tired, they can be easily distracted and in haste may not want to follow a long list of new procedures, instead they want to do what they have to and finish it as quick as possible. A tired or dehydrated nurse is far more likely to improperly handle medications and less likely to be aware of mistakes they are making. A health care worker will not perform at their best unless they have basic needs met. My belief is that inadequate safety practices are what led to the majority of the errors in this documentary. With proper protocols and practices, steps should not be missed, medication errors would not have been made and deaths should not have happened. Hospitals need to be responsible for the systems that they have in place and how they can always improve. When it comes to the Quaid twins who were overdosed twice with 1,000 times more heparin than appropriate the system failed, twice. When it came to Mr. Sheridan who had his pathology reported improperly filed, the system failed. When it came to Julie Thao, the hospital overworked her, and the system failed. Getting the information, which is the first competency in Caputi’s model, means realizing that the system is failing and changing it immediately after it happens. Understanding why it is failing and figuring out the steps you have to take in order to improve it are crucial steps in prevention of additional errors and facilitating culture change. If hospitals realized that there were inadequacies after the first medical death, all of the errors could have been prevented. With engaged leaders, practices that are effective, workable and measurable, as well as implementing good technologies to prevent errors, hospital systems can begin to be fixed (Chasing Zero).

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References Caputi, L. (2021). Think like a nurse: a handbook. Rolling Meadows, IL, Windy City Publishers. QSEN Competenciess. Qsen competencies. (2020). Retrieved April 23, 2023, from https://qsen.org/competencies/pre-licensure-ksas/ . YouTube. (2012, August 3). Chasing Zero: Winning the war on healthcare harm. YouTube. Retrieved April 23, 2023, from https://www.youtube.com/watch?v=MtSbgUuXdaw .

chazing zero paper

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