Thread by @CassieY4

While the venn diagram between hospital work & police work aren't 100%, they do share many similarities -- we're both forward facing to the public, we work with people from all walks of life, and we're both threatened with personal violence.

1x

And, sometimes, sadly, people do lose their lives.

When you accidentally harm someone at the hospital, it's called an sentinel event.

Immediately afterwards a fleet of people step in and consider what happened, how to fix it, and how to stop it from ever happening again.

2x

At my old hospital, we had a pediatric nurse float over to care for a pediatric burned patient.

She put oral oxycodone into an IV line.

Now, already, there's ways to prevent damage from taking place -- oral oxy is a vibrant pink-orange....

3x

Because you're supposed to see the differences between the two and not accidentally give it IV, ever.

The patient's mother saw this pink colored substance creeping up the IV line, and said, "Wait a minute," and the nurse stopped it immediately.

It didn't reach the pt.

4x

But the nurse still reported it, because we've inculcated a culture of self-reporting -- because reporting incidents that cause harm is more important than protecting ourselves from the possible flak from having harmed and then lied about it.

Because....

5x

You can't fix systemic problems if no one knows they exist. (Or, in the police's case, actively lie about the situation that happened, etc.)

You have to be held accountable -- as an institution, if not on the personal level -- for errors.

Otherwise nothing changes.

6x

In our case, immediately thereafter, we reconfigured the way that we gave oral medication, so that things drawn up in oral syringes could not luer lock onto IV lines and vice versa.

All oral meds had to be given via these new un-attachable syringes.

7x

There was training, there were mass purchases of new syringes, and there were frequent reminders about how to do things the New Right Way....

All for a medication that didn't even hurt the patient.

That just came close to possibly-wossibly hurting a patient.

8x

But, because we believed that all patient's lives were valuable -- because, uh, yeah, they are -- we bent over backwards to make sure that there was no way we could ever make that mistake again.

9x

In my time working at different facilities, I realized that each facility had had its own reactions to their own sentinel events -- my new facility doesn't go to such extremes to make sure meds don't go down the wrong route.

10x

Instead, my new facility has ammmaaazinnngggllly stringent blood hanging procedures -- because they once killed a person, by giving them the wrong blood.

And my old facility doublechecked even subq heparin -- because they once OD'd some kiddos.

11x

So I get that there's not like a one-size fits all guidelines as far as 'exceptionally safe nursing' practices, and that it's highly dependent on what's gone down at the facility where you're at....

12x

But what I do know is that each facility takes these instances unbelievably seriously, and that each facility strives in their own way for safety-perfection, ie, the state in which no one who comes in leaves the worse off for having come in.

13x

Patient's illnesses might get them, but it's not-the-fuck because of us (as best as we're ever, ever, ever able to do.)

14x

It is a shame that police don't have access (apparently?) to the tools that we do:

Personal accountability, encouraged at the local and managerial level
The ability to re-train
Re-purchasing appropriate equipment (and taking away equipment that no longer serves a purpose)

15x

Until they can figure all of that out -- they really just need to turn in all their guns.

Any facility having this many sentinel events would be, very justly, shut down.

16/16