Quality Assignment
Mariah Smith
Kettering College
Abstract
This project developed in a healthcare research course is being used in the BSN
Completion project to support the following learning outcome: Uses professional nursing
judgment, informed by Christian principles, moral and ethical reasoning, professional nursing
standards, and evidence-based practice to promote health, prevent disease, and provide safe,
competent, whole-person nursing care across the continuum of health care. This paper was
written after viewing a documentary titled “Chasing Zero” (Denham, 2010). This documentary
explores the idea of human error in a health care setting and what we can do as a population to
strive for “zero” mistakes. This supports the desired learning outcome because of the ethical and
moral principles discussed. It also supports the patient care that is safe and competent and
focused on nursing judgment and ethical principles. This paper explores this topic further.
1. As a healthcare provider, what is your initial response to this video? After watching this
documentary, I felt amazed at how many mistakes are made on a daily basis in health care.
While I’m sure I’ve made more mistakes than the few I can think of, none of them have been
serious and all have been caught early on, i.e. forgetting to open the clamp to a secondary
antibiotic infusion and only allowing the maintenance fluid to run. There are mistakes that are
just common error such as that but the mistakes that are life-threatening are things that can be
prevented regardless of human error. I hadn’t heard of this documentary so watching it really
shocked me. I guess I was a little naïve to the fact that such terrible and fatal mistakes have been
made. I understand the medication vials and similar packaging of supplies because that happens
often. In the last 3 months our Zofran vials have changed colors 3 times. But regardless of
manufacturing, we as nurses are held to a high standard. If we are putting ourselves in positions
where we are working too much or not getting the rest we need, that is our fault. If we are not
doing our double and triple checks on medications and treatments, that is our fault. The
documentary is right when it says these can be prevented.
2. Reflect on the discussion forum in this module. You were asked to develop 2 policies that
will increase consistency in care...while maintaining your responsibilities as a manager.
Does this video change your thoughts on those policies? What techniques could you
incorporate into your policy to ensure quality care and patient safety? Not necessarily. My
policies were directed at safe staffing and the creation of an acuity tool that will better
accommodate our patient assignments and staffing situations. I think this type of policy is vital
when talking about what this documentary has to say. Safe staffing is a key factor in nurses
making mistakes. When staffing is not optimal and patient care assignments are incredibly
heavy, we do run the risk of making mistakes. While it is still our responsibility to prioritize our
patient care and double and triple check our work, understaffing makes that difficult to do
sometimes. Some techniques that could ensure quality care and patient safety would simply be to
design a patient assignment tool based on acuity that will help each nurse to feel like they aren’t
carrying the weight of the world for the next twelve hours. Too often does one nurse get a
heavier assignment than another and/or too often does a unit stay understaffed regardless of what
the patients require.
3. Is chasing zero realistic? What is occurring in practice and in research that supports
your answer? What impact does leadership within an organization have on chasing zero?
The idea of “chasing zero” is realistic in my eyes. When I think of that phrase and this
documentary, I imagine that “chasing zero” doesn’t necessarily mean we are going to get to zero.
Human error does occur like the documentary states, but these fatal errors are uncalled for.
Maybe I’m just hard on myself as a nurse but I hold us to very high standards and I think that’s
what this documentary is doing as well. It’s important to remember that mistakes will happen.
It’s also important to remember our responsibility. Leadership can help support this by making
sure the units are in optimal working conditions and ensuring that when a medication or supply
may look the same that they are taking the measures to prevent an error from occurring.
Especially those fatal ones.
References
Denham, C. (Producer). (2010). Chasing zero [Documentary]. United States: Summer
Productions.