Just Culture, Medication Error Prevention, and Second Victim Support Needed in Nursing Curriculum

Preparing professional nursing students to administer medications to patients successfully after they graduate is a fundamental goal of academic nursing programs. But what happens in the process of learning when a student nurse makes a medication error? Despite a solid curriculum, simulated experiences, and sophisticated faculty guidance around the basic knowledge, skills, and attitudes associated with medication administration, some nursing programs operate within a culture that is disciplinary and punitive, meting out official reprimands, remediation, failing grades, additional work assignments, or even dismissal from the program when a medication error happens. This appears to be the case following an event that was recently reported to ISMP by the concerned colleague of a nursing student.

The Event

A student nurse provided the mother of an 11-year-old postoperative patient with a packet of an amino acid, vitamin, and mineral nutritional supplement that promotes wound healing. He observed the mother adding it to the bottle of sports drink that the child was sipping. Because the nutritional supplement was not technically a “medication” in the student’s mind, the student never thought to scan the barcode on the packet prior to giving it to the child’s mother. Later, when documenting the nutritional supplement on the child’s medication administration record (MAR), the student began to think that perhaps he should have scanned the nutritional supplement packet. 

Response to the Event

The student nurse immediately reported the event to his instructor, and together they went back to the child’s room and scanned the empty nutritional supplement packet that had been added to the child’s sports drink. The instructor discussed with the student the need to scan all products, including nutritional supplements, prior to administration. However, although the correct nutritional supplement had been given to the right patient at the right dose and time, and was being administered (sipped by the child) by the right route, the instructor identified the event as a “medication error” for which the student nurse was “severely” punished (no description of the “severe” punishment was provided). The instructor did not require the student to complete a hospital medication error report. 

In response to being “severely” punished for making a “medication error,” the student thought that the event might have been a “near miss” and suggested this to the instructor. In response, the instructor issued a letter of reprimand to the student. In the letter, the instructor told the student that, by claiming the error was a “near miss,” he had failed to demonstrate self-accountability for the medication error. The instructor also suggested that a “near miss in nursing can be fatal.”  

Concerns with the Response

ISMP has multiple concerns with the scenario described above. Of course, we are troubled that the instructor did not require the student to report the event in the hospital because other nurses, both students and graduates, may have the same question of whether nutritional supplements need to be scanned prior to administration. And we cannot overlook the fact that the student categorized the event as a “near miss.” In 2009, more than 3,800 practitioners participated in an ISMP survey regarding the definition of a “near miss.”¹ Nearly 90% of the responding practitioners defined a “near miss” as an error that happened but was caught before it reached the patient. ISMP agrees that a “near miss” is an error that never reaches a patient; thus, a “near miss” cannot result in patient harm (but could have if the error reached the patient). Since 2009, ISMP has referred to “near misses” as “close calls” since this terminology is more precise.¹

Most concerning is that the student nurse was “severely” disciplined for the event, which was classified as a medication error. We do not have details regarding the specific disciplinary action taken and why. We only know that the student received a letter of reprimand which we were told suggested he failed to accept accountability for the error by calling it a “near miss.” Nursing program curricula often does not support effective faculty and student acquisition of the knowledge, skills, and attitudes required to understand human fallibility and the risk of medication errors within a Just Culture, and how to respond fairly and compassionately to health professionals who make an error—the second victims of the error. Reasons for these curriculum vulnerabilities are deeply rooted in an overly punitive culture that has dominated healthcare with an unrealistic expectation of “zero errors” and with perfect compliance with policies and procedures despite unexpected challenges. In this case, the instructor failed to acknowledge that the student self-reported the event, and the resulting punitive response to the event was likely viewed by this student and others as a deterrent to reporting, crippling the ability to learn.

ISMP would categorize the event as neither a near miss nor a medication error. Perhaps the student nurse’s actions represented an at-risk behavioral choice associated with not scanning a nutritional supplement, which should be addressed by coaching, not by disciplinary sanctions. Or it may simply represent a process error due to a knowledge deficit if the student nurse did not know he was required to scan the nutritional supplement (and thus, did not choose in the moment to bypass the scanning process).

Impact of a Punitive Response

While perfection may be a laudable target, it can never be a realistic expectation given all that is known about human fallibility. Nursing faculty and students need to fully understand the possibility of gaps in knowledge, human fallibility, and the human tendency to lose perception of the risks associated with behavioral choices that may be made when facing unexpected challenges. They need to understand why medication errors happen and how to reduce their occurrence. They need to be comfortable seeking guidance when gaps in knowledge occur and reporting errors without fear of reprisal. Students need to appreciate the tenets of a Just Culture and compassionate second victim support while personally experiencing their immense benefits within the culture of their undergraduate training. Given the formidable link between the causes and prevention of medication errors, Just Culture, and second victim support, it is important to teach students these three nursing competencies in unison and to provide an environment that models and supports these competencies. Only together will they help form a solid foundation for preparing nursing students to successfully administer medications and respond to medication errors.

Available Resource

ISMP recently posted a white paper, Just Culture, Medication Error Prevention, and Second Victim Support: A Better Prescription for Preparing Nursing Students for Practice, on our website.² ISMP participated on a team of experts who developed this white paper, which serves as a call to action to nursing programs to change the way they are preparing nursing students for practice. The white paper includes recommendations for faculty to: 1) Define and create a Just Culture in their own programs; 2) Weave safety- and quality-focused components into the nursing curricula beginning with the first semester; 3) Educate nursing students about human fallibility and how to minimize errors; and 4) Establish a second victim response team within the nursing program. Using the Quality and Safety Education for Nurses (QSEN) format, a set of new critical competencies for Just Culture, second victim support, and medication error prevention is provided, as well as links to resources.

References

1. Institute for Safe Medication Practices (ISMP). ISMP survey helps define near miss and close call. ISMP Medication Safety Alert! Acute Care. 2009;14(19):1-2.
2. Jones J, Treiber L, Shabo R, et al. Just Culture, medication error prevention, and second victim support: a better prescription for preparing nursing students for practice [White paper]. Kennesaw, GA: WellStar School of Nursing, WellStar College of Health and Human Services, Kennesaw State University. 2021.