The greatest fear of any health care professional is harming a patient. I am no different. Like many others I think of medication errors as the primary way that I can harm a patient. During a nursing school lecture, I learned about Josie King. The short version of Josie’s story is that at 18 months she climbed into a hot bath and received first and second degree burns. She was healing well, and was expected to make a full recovery. However, mismanagement of pain meds and dehydration resulted in Josie’s death. This was a shock to me. It never occurred to me that how I cared for a patient could have such a poor outcome.
A year later I am sitting in Telluride at a patient safety roundtable and see two more videos about how mismanagement of care resulted in death. I hear John Nance talk about human fallibility and the expectation that I will make an error at some point despite how careful I am. So I wonder – when will that happen to me? How will I respond? If today’s discussions are any indication, I have hope that I will be surrounded by nonjudgmental professionals and together, we will determine how to prevent that error from happening again by anyone else. My mission, if you will, is to be the best nurse I can be. Owning responsibility for my actions and being mindful are just part of the job. These are touchstones that will guide my practice. Patients expect that and I can’t blame them. After all, I am the patient’s advocate. If I don’t look out for my patient, who will?