I was appointed as asst chair of patient safety committee when I joined the hospital. My asst superintendent wanted someone who with experience and new idea to lead the team. The commitee major task is to control and manage the extraordinary incidence in the hospital, ranging from patient fell down to drug safety... My assignment was to monitor and counter sign each cases - deciding which case should be brought up and root course analysis (RCA) should be done. During this period, I had become one of the "black badge" in the hospital. When ever I was seen discussing c the matron or other head nurse, the nurses would gossip around that I was complaining and trying to dig shxt out of them...
In a matter a fact, I dislike the job, but I wanted the hospital to become a better place - not only to work, but to all the patient. But the fact was the other way round, you can see violation of standard operation procedure here and there. Workers decide the way the they do their job - SOP is for reference and not comply.
I was a little fed up about the situation and asked for a leave. I finally got it "exchanged" . I resigned as asst chair but remained in the committee and focus on the RCA team.
Recently I had three similiar incidents which ended up differently. It all started from the pharmacy....the pharmacist had "accidentally" and "wrongly" enter a wrong drug name while transcripting the prescription to the pharmacy entry system;a wrong entry would lead to wrongly despensing of such drug to the ward. well, when the system works well, the drug would be double checked in the ward and error would be noted and correction would be done so the patient would not recieve any medication that he is not suppose to have.
However that were not the case for all of the incidences I mentioned. In one of the cases, a fourth generation cephalosporin was wrongly entered as a second generation cephalosporin.... a stat dose was ordered and the pharmacy had entered it correctly and a stat dose of such drug was sent to the ward and this nurse A had given the stat dose. However the regular 4th gen ceph was wrongly entered to the system and on D2, a 2nd gen ceph was despensed to the patient. On D2 this nurse A had however violated the SOP: she did not perform a double check before given the drug; she had to checked the drug with the dispensing sheet( it was transcripted from the medical order sheet(this sheet was printed c clear capital letter)) and she had ignored/or maybe forget that the packaging was different from the drug she given to her patient last night. She had injected the patient with the 2nd gen ceph.
And then the evening shift nurse and then the morning shift nurse and then .....had given the drug without properly checking the label of the drug and the order sheet . (there were 21 "and then" in total: yes 21/3 = 7 days!!!!) During this 7 days no staff had discovered the error - the drugname on the UNIT DOSE sheet, the order sheet and the drug label was totally different. On D7, the drug was renewed and a new prescription was sent down, this time the entry was correct and the 4th gen ceph was sent to the ward. The nurse (not A) of coz, had discovered that a different drug was given and they had tried to file a complaint to complaint the pharmacy of wrongly dispensing drug. And later the truth was revealed.....well, no one seems to care after the incidence...
Well, the patient did got better - he was given a double dose of 2nd gen ceph ... lucky he got better and did not suffered from any other damage.
"TOO ERR is human, to forgive is DIVINE" ---- but this is far beyond forgiveness....the chances of having another incidence is 1/536870912 in other hospital but with the current staffing, I think it is 1/2.......
The RCA report will be my responsiblility, but before I seen the investigation report and conclude my report, I knew the conclusion - negligence.
But why these staffs dare to do so? this is another management problem: in the past only finger countable(to be exact 1 hand) staff were reprimanded for what they did - most of the time, oral warning was done....and also only handfull of staff were being praised .... that was the main reason...
TIRED -- I told Lem, I am prepared to resign .... no sense of security working with those staff...
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