“Since 1999 we’ve known that more than hundred thousand Americans die every year because of healthcare harm, that’s the equivalence of more than ten jumbo jet airliners crashing every single week,” states Dennis Quad, patient safety advocate, in the documentary Chasing Zero. (Chasing Zero, 2012). The documentary focuses on the problems that are taking place in the healthcare system, resulting in unintentional harm of patients. While searching for a solution, Dennis Quaid, a parent to two victims of human error, met, Dr. Charles Denham, the head of a medical research organization called TMIT, Texas Medical Institution of Technology. TMIT specifically researches in patient safety and was able to put Quaid in touch with other victims of human error. The families of victims have come together to form an army against unintentional harm.
They push for change by telling their experience, hoping to fix the faulted health care system. They work towards having the number of cases of unintentional harm in hospital, due to human error, equal “zero” one day. The result of their movements has led to technological advances, improved communication, and a safe healthcare environment. The purpose of this paper is to discuss medical errors portrayed in Chasing Zero, identify critical competencies, as well as obstacles in healthcare, and examine the positive effect of teamwork.
Errors in MovieThroughout Chasing Zero, the faulty healthcare system is shown to lead to various unintentional harm to patients. One faulty system within the health care system shown was similar labeling and packaging on drugs. For example, Dennis Quaid’s twins were born healthy, but soon their lives were in danger when a medication error occurred. Twice, the twins were given a thousand times the amount of heparin they should have received. They should have received 10 units, but were given 10,000 units instead.
These medication errors were most likely caused by the similar labeling on the heparin vials. The ten units of heparin had a light blue label, where the 10,000 units of heparin had a dark blue label (Chasing Zero, 2012). When turned slightly on the shelf, it is almost impossible to distinguish which is which. With the labeling on the bottles being far too similar, preventable harm, like the twins case, was bound to occur. Another common error within the healthcare system is communication errors. For instance, in Pat Sheridan’s case, his life was ended prematurely due to a report being misplaced.
Pat had an MRI, but the results were filed into his chart without anybody viewing the results. The results were not viewed until six months later, after his second MRI. Due to this filing error and communication error, by the time the tumor was seen, it was already too big. If the filing error and communication error had not occurred, Pat would have begun treatment sooner.
As a result, surgeons had to remove most of Pat’s spine, leaving him paralyzed from the waist down. Pat’s cancer was so aggressive, it soon took over his body, resulting in death. If Pat’s results had not been misfiled, his cancer would have been found sooner, which could have potentially saved his life. QSEN competences: Quality ; Safety and InformaticsQSEN, Quality and Safety Education for Nurses, has developed six competences for nursing programs to follow with the hopes of preventing as many human errors as possible. The two most important competencies include informatics and safety. Informatics is the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making (QSEN, 2018).
Technology today has given healthcare a safer way to administer medication. In many hospitals, in order to administer medication, the nurse must first scan the medicine then the patient’s wrist band to make sure it is the right dosage and right patient. This type of technology would have helped the twin’s situation, as there would have been a higher chance that the right amount of heparin would have been administered. Safety is when harm is minimized to patients through both system effectiveness and individual performance (QSEN, 2018). Within Chasing Zero, the similar labels on medication led to an unsafe, faulty system. Currently, medications have distinct labeling and different caps to help prevent nurses and doctors from grabbing the wrong one. In the twin’s case if the heparin had more distinct labels and caps, it would have helped the nurses to prevent the unintentional harm that occurred.
Obstacle in Culture of SafetyOne of the biggest obstacles in implementation of a culture of safety in the work place is the culture of silence about the cases of preventable healthcare harm. The fear to report medical error incidences founded within doctors, nurses, and other medical personnel sprouts from the risk of possible punishment. Possible punishment for such error can include loss of job, loss of license, legal charges and/or jail time. In spite of the fact that a factor playing into medical errors is the element of a faulty health care system, human error is now even less likely to be reported due to the possibility of criminalization on some mistakes (Chasing Zero, 2012).
If one mistake could cause a lifetime in jail, the people committing these mistakes will soon resort to silence with the purpose of protecting themselves.On the fourth of July, register nurse, Julie Thao, worked a long double shift, then had to work the following morning. During her morning shift, when preparing a patient for her delivery, Julie followed the nursing unit guidelines plan accordingly.
However, this soon became a nightmare. With the healthcare systems flaws, similar labeling and IV connectors, Julie soon committed a predictable human error. Julie gave the patient the anesthetic instead of the antibiotic, which resulted in death. Julie was soon fired, lost her license for incompetence, and criminally indicted.
In order to avoid jail time, pleading a misdemeanor was all she could do (Chasing Zero, 2012). Though a mistake was made, never was Julie proven incompetent through evidence. The loss of Julie’s license because of the presumption of being incompetent, without evidence of incompetence, was unfair. Julie was truly the second victim of a very bad healthcare system consisting of too many hours worked and similar drug size, shape and labeling. Julie’s case led to the creation of a new National Quality Forum Safe Practice called “Care of the Caregiver. The “Care of the Caregiver” practice entails protecting and helping those who are involved in accidently harming patients (Venkatesh, 2015). Although “Care of the Caregiver” was created after Julie’s case, not everyone could be as lucky as Julie and get away without serving jail time.
In fact, in another case, a two-year-old girl once received an injection of saline solution twenty times the intended concentration, which lead to a fatal outcome. After investigation, it was found that on a busy day, a pharmacy technician, working under pharmacist, Eric Crop, accidently mixed the solution incorrectly. As a result of Crop signing off on this technicians work, he was convicted of involuntary manslaughter and sentenced to time in prison (Chasing Zero, 2012). Criminalizing human error in healthcare, the way Eric was convicted for involuntary manslaughter, will delay the process of fixing a faulty system.
If medical personal becomes hesitant to report medical errors in fear they will end up like Eric Crop, ultimately, all opportunities to correctly the root cause of the issue in the healthcare system will be abolished. Though Eric and Julie were both investigated and legally charged, there are many similar cases that go undocumented. In a nurses’ or doctors’ attempt to protect their own practice, silence is the common resolution. Without talking about the issues at hand with the faulty healthcare system, no solutions will surface. The cause and effect chain from silence is the greatest obstacle in healthcare for safety risk, as silence will lead to keeping underlying issues hidden.
Interprofessional TeamThe cohesive interprofessional team can create a culture of safety and improve quality of care in the workplace by uniting professionals to create the best care for a patient. With an interprofessional team working together, patient centered care is present. An example of where an interprofessional team collaborating effectively could have saved a life is in Pat Sheridan’s case. If Pat’s nurses, doctors, receptionists, etc., would have provided patient centered care and worked collaboratively, it is likely that someone would have realized his chart was never read. Pat could still be alive today if the results were read directly following the procedure.
Future NurseAs a future nurse, the most important principle I will embrace after watching Chasing Zero is patient safety. As a nurse, I will be sure to use the technology and team available to me to provide the best care to my patients. Additionally, when administering medication, I will be very cautious and double check the medications and dosages before administering.
However, since I am only a student right now, I will use the idea of patient safety and preventable harm in my studies and clinicals. Chasing Zero has also ingrained into my mind the idea that I am soon to be in a profession where all of my actions will affect the lives of others, and any wrong action will have consequences. ConclusionThe documentary Chasing Zero highlights the disastrous, deadly effect medical errors can have on patients and their families. The goal of this documentary is to create awareness about medical errors and to stop them from occurring. The army of victims of medical errors are working together with the hope to change the statement of “more than a hundred thousand Americans die every year” (Chasing Zero, 2012) to ‘zero Americans die every year,’ due to healthcare harm. As awareness increase, technology advances, and interprofessional teamwork evolves, medical errors are likely to decrease and someday the chase to zero may be reached. References QSEN Competencies. (2018).
Retrieved from http://qsen.org/competencies/pre-licensure-ksas/#safetyTMIT1. (2012, Aug 03). Chasing zero: winning the war on healthcare harm. Video file. Retrieved from https://www.youtube.com/watch?v=MtSbgUuXdawVenkatesh, A.
K. (2015, April). Emergency care and the national quality strategy: highlights from the centers for Medicare ; Medicaid services. Retrieved from https://www.annemergmed.com/article/S0196-0644(14)00616-7/fulltext
