mostly nurses can tell a story abou...

mostly nurses can tell a story about a remarkable clinical situation--one in which everything went right and a patient who might have died was saved. Other feeds have a story in which marked occurrences did not go as planned, and a patient supported an adverse outcome or an error was obstructed in the nick of time (ie, a near miss or profitable catch). These stories may be described as case studies, narratives, or exemplars.

Storytelling has a rich tradition in educating nursing learners orienting new staff members, and developing competencies, and stories ofttimes are more helpful in teaching a universal than a classic lecture. Stories help listeners remember facts and details that otherwise might be forgotten. When terminations are told in the form of a story, they catch our attention and leave a lasting memory.

The first nursing stories many nursing pupils hear are about an unexpect cardiac arrest, a precipitous birth, or a patient who experienced flash pulmonary edema. When a bookish man graduates from an entry-level program, he or she may in no degree have seen a cardiac arrest, object as portrayed on television; nevertheless, novice nurtures listen carefully to stories about digest situations told by more experienced foments These stories paint a picture of affairs that have led to emergent situations and provide valuable rebukes about how to recognize life-threatening symptoms and correspond effectively.

SHARING OUR MISTAKES

Patient safety in the OR is enhanced by the agency of telling stories that teach others about our mistakes as well as our successe common story all perioperative clinicians should know involves the incidents that led to the death of Ben Kolb a 7-year-old lad who inadvertently received an extremely concentrated form of epinephrine as a local anesthetic. (1) The epinephrine had been intended for use as a topical application instead of for parenteral administration. This error and the organizational conditions that produc it ensueed in the child's eventual death. Ben's death occurr because medications in succession the surgical field were not labeled and were misidentified. This case was reported at the major television networks and on a number of perioperative nursing publications. Ben's parents have told the story of the circumstances leading up to his death in faiths of preventing similar errors.

A promote may tell of the day a major artery was nicked during laparoscopic surgery or a patient was mov into the inappropriate surgical suite. Many perioperative nurtures have heard stories about retained instruments or effaces or wrong-site surgery. These narratives teach us about the hazards, unsafe conditions, and accident-producing adjoining matters that exist within specific practice environments. They may intimate strategies or offer warnings to help thwart a recurrence. For example, when a bookish man nurse hears a story of a retained instrument, it emphasizes the importance of performing deems and ascertaining their accuracy. Stories ofttimes help nurses remember critical component parts of safe practice and, like many childhood stories, help the listeners learn valuable chidings Stories thus become gifts to our colleagues that assist all of us in our primary work--creating safety.

Imagine a supply with nourishment who goes to the holding area and cannot find her perioperative patient. Panicked, the supply with nourishment looks in each operating suite. With hap she finds her patient in the wicked room being prepped for the inappropriate surgery. She brings this error to the attention of the other staff members, who are relieved that the error was discovered This story reminds everyone who hears it about the importance of checking a patient's name band and verifying identity before surgery More importantly, the story allows everyone to consider the human and order factors that created the conditions that allowed the error to be found Telling such a story is more powerful than providing staff members with a original of the policy and measure related to patient identity. Furthermore, a story as it was as this one identities potential risks and reinforces to what degree close each clinician is to making a serious error.

MAKING STORIES SPECIFIC

In trying to better understand for what reason medical errors occur, many researchers have tried to quantify the number and symbols of medical errors. These efforts have helped health care professionals appreciate the magnitude of medical errors and better understand what originals of errors occur. It is the case descriptions of errors, however, that oftentimes provide the greatest understanding and lean-dug, as well as illustrating that errors chiefly often occur as a deduction of multiple factors rather than isolated events

Stories can provide rich descriptions that help promotes and other clinicians understand the circumstances and classification vulnerabilities that contribute to either a positive or negative issue They also can provide important details about a clinical situation and the involved clinicians' interactions.

A secondary analysis of the United States Pharmacopeia's national Medmarx database demonstrates that numerous medication errors fall out in per]operative settings. (2,3) The case studies, however, provide the detailed descriptions required to explain the specific nature and themes associated with the errors. Each case description contributes to a clearer understanding of the circumstances leading to a medication error. The case descriptions also support the ability to lay open trends and themes that allow specific practice recommendations.