Introduction
One of the most important goals of healthcare teams is to ensure patient safety. Still, individual team members’ characteristics can lead to medication errors. Identifying, reporting, and managing these errors promptly is essential to prevent adverse patient outcomes. In the present case, the nurse administered ibuprofen and aspirin to a patient on warfarin. Drug interactions resulting from this combination could cause the patient to bleed more easily, and thus the error compromised patient safety. It is essential to act promptly to protect the patient and prevent similar occurrences in the future.
Main body
Firstly, it is essential to note that standards of professional behavior for nurses necessitate reporting medication errors, regardless of whether or not they threaten the patient. In the present case, the patient is unlikely to suffer significant health consequences as long as they are not injured or bleeding. Reporting an error would help to avoid making the situation worse by administering more blood thinners (clexan). Therefore, the first thing that I would do in this situation is to talk to the patient’s physician to inform them about the mistake and clarify what modifications should be made to the treatment, if any. I would also notify the nurse manager or leader present on the shift so that the patient could receive the necessary attention and consideration during any manipulations. In addition, I would practice disclosure and transparency by informing the patient about the error and the need to make short-term modifications to her pre-up treatment. I would take care to explain to the patient that, at present, her life is not in danger, and it is likely that the error will not have any negative consequence on her health. In this way, I would be able to engage the critical team members involved in the care process, including the patient, and establish excellent communication on the problem.
Throughout my encounters with other team members, I would avoid blaming the other nurse for the error because this could lead to conflicts within the health care team and impair future teamwork. For example, if the patient believes that the other nurse lacks qualifications or experience, she might not trust her in the future, which could affect the therapeutic relationship between the two. Similarly, if the nurse manager or the physician blame the nurse for the error, it could affect trust within the team and create obstacles to teamwork in the future. Hence, it is crucial to highlight that mistakes can occur due to a variety of factors and that they do not always depend on the nurse’s level of knowledge or professionalism.
Once patient safety is ensured, and communication is established, I would also make plans to approach the other nurse during her next shift, both to inform her about the error and to prevent future mistakes. In talking to the nurse, I would use effective feedback provision techniques, such as sharing resources that could be used to clarify information when doubt, asking about why she thinks the error occurred, and suggest practical strategies to ensure patient safety in the future. Providing feedback in this way would show my support and willingness to help while also drawing the nurse’s attention to the need for improvement, thus having a positive effect on teamwork and patient safety in the unit.
There are various factors that influence teamwork by facilitating or impairing it. Understanding how these factors work together in practice can help to improve teamwork both in the questions of patient safety and generally throughout the unit. First of all, communication styles play a crucial role in teamwork because collaboration between team members is not possible unless they all share information in a way that each can understand. Research shows that excellent, transparent communication between team members supports teamwork, whereas poor or inadequate communication reduces outcomes (Gluyas, 2015; Reising et al., 2017). In the present case, communication was adequate since the nurse recorded the medications given to the patient in her chart. This helped the morning nurse to identify the error and take steps to reduce its potential effects on patient outcomes, thus supporting patient safety. However, the lack of personal communication and the focus on written communication could be considered a barrier in this situation, since the night nurse could have told her colleague about the medication face-to-face, and action would have been taken more promptly.
Leadership style also has an influence on teamwork in healthcare settings since it can influence organizational practices and the level of oversight. According to Dyess, Sherman, Pratt, and Chiang-Hanisko (2016), nurse leaders can “contribute to improving work environments, unite teams, and implement changes needed to advance healthcare” (para. 3). Leadership can thus affect collaboration and teamwork by shaping the values and actions of team members, as well as the working environment, policies, and standards (Polis, Higgs, Manning, Netto, & Fernandez, 2017; Regan, Laschinger, & Wong, 2016). In the present scenario, there was no evidence of leadership during the night shift, which could have affected the outcomes of the medication error. For instance, if the night nurse had more support from leaders during the night, she could have inquired about the interactions between warfarin, NSAIDs, and aspirin and verify the prescription.
Lastly, team cohesion also appears to have been an essential factor in the case. Team cohesion reflects “the dynamic process of team members working closely together to achieve a team goal” (Kao, 2019, p. 2350). Consequently, team cohesion has a significant effect on communication and collaboration within the team, leads to better relationships between members, and helps teams to achieve excellent results (Bell, Brown, Colaneri, & Outland, 2018; Kao, 2019). In the present case, there was little evidence of team cohesion due to limited interpersonal communication. Based on the little information available, it can be suggested that team cohesion is reduced, which is a barrier to effective teamwork. Enhancing team cohesion would require nurses to communicate more with one another about shared goals, performance, and activities.
Conclusion
Each of the three factors identified here would also affect how the problem is resolved and whether threats to patient safety will persist. Differences in communication styles between team members could impede the process of solving the problem by delaying information sharing. Ineffective leadership that does not provide sufficient support to workers would also threaten the outcomes of the case by ignoring the issue or leaving nurses to solve it on their own. In the same way, the lack of team cohesion would affect the risk of repeated errors in the future. If team members do not work toward the shared goal of increasing patient safety, they will likely fail to achieve long-term results. Therefore, addressing gaps in each area would contribute to a successful resolution and help to improve patient safety in the future. While identifying these gaps and making plans to remedy them is the responsibility of leaders, all team members should participate in improvement efforts to yield the best results.
References
- Bell, S. T., Brown, S. G., Colaneri, A., & Outland, N. (2018). Team composition and the ABCs of teamwork. American Psychologist, 73(4), 349-362. doi: 10.1037/amp0000305.
- Dyess, S. M., Sherman, R. O., Pratt, B. A., & Chiang-Hanisko, L. (2016). Growing nurse leaders: Their perspectives on nursing leadership and today’s practice environment. The Online Journal of Issues in Nursing, 21(1). doi: 10.3912/OJIN.Vol21No01PPT04.
- Gluyas, H. (2015). Effective communication and teamwork promotes patient safety. Nursing Standard (2014+), 29(49), 50-57. doi: 10.7748/ns.29.49.50.e10042.
- Kao, C. C. (2019). Development of team cohesion and sustained collaboration skills with the sport education model. Sustainability, 11(8), 2348-2362. doi: 10.3390/su11082348.
- Polis, S., Higgs, M., Manning, V., Netto, G., & Fernandez, R. (2017). Factors contributing to nursing team work in an acute care tertiary hospital. Collegian, 24(1), 19-25. doi: 10.1016/j.colegn.2015.09.002.
- Regan, S., Laschinger, H. K., & Wong, C. A. (2016). The influence of empowerment, authentic leadership, and professional practice environments on nurses’ perceived interprofessional collaboration. Journal of Nursing Management, 24(1), E54-E61. doi: 10.1111/jonm.12288.
- Reising, D. L., Carr, D. E., Gindling, S., Barnes, R., Garletts, D., & Ozdogan, Z. (2017). Team communication influence on procedure performance: Findings from interprofessional simulations with nursing and medical students. Nursing Education Perspectives, 38(5), 275-276. doi: 10.1097/01.NEP.0000000000000168.