Chasing Zero and QSEN Competencies
Karissa Mae Gabot
Seton Hall University
Chasing Zero and QSEN Competencies
Safety in healthcare settings, such as hospitals, should not have to be a concern especially for patients. Unfortunately, medical errors continue to persist in healthcare, which in turn affect patient’s lives permanently. The film, Chasing Zero: Winning the War in Healthcare Harm discusses real-life cases of medical errors and the movement towards reducing the number of malpractice that occurs. In an effort to reduce the harm that occurs towards patients, Quality Safety Education for Nurses (QSEN) provides a guideline for nurse educational programs to teach their students so that the care they provide quality care in the workplace. With the combination of the QSEN Competencies and awareness of medical errors, patient care can improve drastically.
Medical Errors in Chasing Zero
Medical errors that were explained in the film could have been avoided if the healthcare providers contributed more attention to the care they were giving patients and similarities in medicine packaging. Human error is very likely to occur when those providing care are not contributing their full attention and is only heightened when two medications look almost identical. One example was with the narrator’s own family, Dennis Quaid’s children. His newborn twins were in the hospital and needed to be administered blood thinners. However, instead of being administered ten units of hep-lock, the hospital gave the twins ten-thousand units of heparin, twice. This dosage was two thousand times greater than what the twins were supposed to receive, which is a highly lethal dose especially for newborn children. Quaid then went to court in an effort to bring this issue to the attention of the public. The mistake was largely due to the very similar labeling of heparin and hep-lock. The only noticeable difference between two were the colors of the labels, heparin being dark blue and the hep-lock being a lighter blue. After this incident, the labeling between heparin and hep-lock became very distinguishable, while hep-lock remained the same, heparin’s packaging became red and black with an entirely different bottle shape. The simple change in appearance greatly lessens the chance of administering a lethal dose of blood thinner and saves the lives of others.
This medical error could have been preventable if the labels between hep-lock and heparin were more distinguishable from each other from the beginning. Another possible reason for the medical error would be the nurse’s lack of attention while the nurse administered the medication to the twins. The nurse gave the children heparin twice within eight hours; if the nurse or another physician acknowledged the mistake the first time, immediate action and care could have been given to the twins. Instead, the nurse failed to make certain that the children received the right medication and the lives of the twins were put in danger.
Another situation caused by the lack of attention and similar medication packaging was the case of Julie Thao. Thao’s patient was going into labor and requested an epidural. Thao prepared and had both the epidural and a bag of antibiotic in her hand; both have identical medical tubing connectors and are similar in appearance. However, instead of giving the patient the epidural medication, Thao accidentally administered the antibiotic, penicillin. The young mother reacted to the penicillin and went into cardiac arrest, ultimately resulting in her death. Though not justifying the mistake she made, Thao explained that she barely got any rest because she had to work a double shift during the Fourth of July, which was the night before the incident occurred. The death of the young mother could have been avoided if Thao received an adequate amount of rest the night before. However, similar to the situation of Dennis Quaid’s children, Thao’s situation was preventable if the two bags of medication were different enough in appearance to avoid confusing one for the other. Despite the appearance of the medication bags being out of her control, because Thao was the one responsible for giving the antibiotic to the mother, she was the one punished. Thao lost her job and was forced to plead a misdemeanor to avoid prison.
The QSEN Competencies
For Quality and Safety Education for Nurses, also known as QSEN, there are six Competencies that need to be fulfilled: patient-centered care, teamwork and collaboration, evidence based practice, quality improvement, safety, and informatics. Programs for nursing students utilize these six QSEN Competencies to prepare them so that they can offer the best possible care for their patients. QSEN also provides nurses certain expectations in knowledge, skills, and attitudes in each of the Competencies that must be satisfied. Nurses must meet each component in order to lessen the number of medical errors that occur in the workplace and to ensure patient safety.
The first competency of QSEN is patient-centered care. As the name suggests, this aspect of QSEN emphasizes the importance of including the patient when discussing their plan of care. Implementing patient-centered care encourages the patient to become more involved in their treatment and constantly keeps open communication between healthcare provider and patient (QSEN.org). Patient-centered care stresses the importance of respecting a patient’s values and beliefs when developing a plan of care. The awareness of a patient’s values and beliefs helps reduce errors that occur because it encourages doctors to understand that one treatment for a patient may not be applicable for the next patient because of reasons such as their religion or lifestyle.
The second component of QSEN is teamwork and collaboration. According to QSEN, it is defined as “functioning effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (QSEN.org). If a patient has multiple doctors, each of those doctors need to communicate to each other in order to deliver the best care to their one patient, they must all do their best to keep a constant flow of information between each other. For example, if a problem arises with a patient, the nurse on duty must relay that information to the physician and the next nurse that will be taking over. Another example would be that a patient who is seeing several different healthcare physicians. Each physician must let the other doctors know what kind of care they are receiving under their care in case it were to intervene with another physician’s plan of care, it can also help understand a patient more than they did previously. Teamwork and collaboration contributes to the decline of error in the workplace because something as simple as not administering the same medication twice can be avoided.
The next competency that can help reduce the number of medical errors is evidence based practice, or EBP. QSEN defines EBP as “integrating the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care” (QSEN.org). Similar to patient-centered care, EBP focuses on patient values but it also takes into consideration clinical practice. Clinical knowledge is constantly expanding due to the constant research being done so it is the responsibility of the healthcare professionals to always increase their knowledge and keeping up with the research being conducted. EBP emphasizes the use of the scientific method as well as experience so that providers can make logical decisions in regards to a patient’s treatment. Not only does EBP increase patient safety by encouraging doctors and nurses to take their time when planning the care their patient will receive, it also pushes that the specialists always stay informed of the trends in healthcare which can potentially improve their plan of care overall.
The fourth competency that QSEN acknowledges is quality improvement which is defined as the “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (QSEN.org). This competency involves the use of statistics to measure whether a plan of care is effective or ineffective. If data shows that the care is ineffective, the plan would undergo modification and be monitored to see if the change helped increase the number of successful outcomes. Quality improvement works towards creating better, safer treatments for patients. For the creation of more successful care plans, doctors and nurses must work together to decide what would be best for their patients. After the changes have been made, the healthcare providers must determine whether or not the changes were useful or simply did nothing for the patient. Because care is being observed consistently to make improvements, a mistake is less likely to slip past the healthcare providers. If there happens to be a mistake, there are better chances of the mistake can be identified earlier and the problem would is fixed before serious damage occurs.
Following quality improvement, the next QSEN competency is safety. Occupancies of all professions understand that safety should be the top priority. However, QSEN offers those in the healthcare professions an in-depth understanding of safety and exactly what it entails. The website states that safety “minimizes risk of harm to patients and providers through both system effectiveness and individual performance” (QSEN.org). Safety keeps in mind the well-being of both the patient and the provider. For nurses and other physicians, safety is a concern because often times the environments they work in tend to be full of hazards. Some examples would include exposure to infectious disease, toxic substances such as chemicals, and sometimes even patient violence. Also for the patients, if their provider is not observing safe practices, their life may be at risk. Taking precautions in the workplace reduces the possibility of an incident occurring that compromises the safety of both the provider and patient, thus reducing the amount of error that occurs.
The final QSEN competency would be informatics, which is defined as, “the use information and technology to communicate, manage knowledge, mitigate error, and support decision making” (QSEN.org). Since many occupations are becoming largely technology-based, especially in the medical field, it is important to become familiar with the different advancements that occur. Technology is a great tool to have only if users are aware of how to operate the machinery. If not, the technology can potentially become dangerous. Important patient files such as health records are now found primarily on computers and databases; if physicians and nurses are not well-versed in using technology, they will have difficulties in navigating through the database and imputing patient information. Informatics also encourages the flow of communication between different physicians constant. Familiarity with informatics reduces mistakes that can occur in the workplace because if the provider is skilled in how to use technology and how it coincides with its importance in relaying information there are smaller chances of patient data being lost.
For most of the six QSEN Competencies, the emphasis mostly lies with communication and safety. Whether it be between the patient and physician, the patient’s family and physician, or several physicians, successful patient care plans would not be possible if there was not a consistent flow of information within the systems. Also with consistent communication comes with the improved safety of not only the patient but the providers as well. If educational programs taught the QSEN Competencies and employers emphasized utilizing them on the job, the goal of completely eliminating medical errors is within reach.
QSEN Competencies applied in Chasing Zero
In Chasing Zero, the goal is to inform the public on how healthcare systems are changing in order to achieve the goal of zero medical errors. Hospitals are coming up with new systems and technology that helps reduce human error and improves patient safety. Though all the QSEN Competencies are observed in new procedures seen in the film, safety and informatics will be the focus of this particular discussion.
The first competency, safety, focuses on reducing human error and avoiding harmful applications in the workplace. Safety works towards reducing error where it is possible to occur. In Eric Cropp’s case, human error was the cause of his crime of involuntary manslaughter. Cropp was a pharmacist who delegated the task of mixing saline solution incorrectly but because Cropp delegated the task, he was responsible for the patient’s death. Though it may have been a busy day, the outcome was avoidable only if the technician mixed the solution correctly or if Cropp had not given the responsibility to someone else. Small, minor mistakes can lead to a lifetime of consequences and anything that has the potentiality to harm a patient should be handled with care. Later on in the film, checklists were introduced to create a better sense of safety in the workplace. It is possible that if checklists were available to them, it would have provided the technician with the correct ratios for a safer saline solution.
The QSEN competency of informatics recognizes why the use of technology and information is important in the healthcare community. Like checklists, the availability of technology helps reduce human error by confirming medications before the patient receives it. Revisiting Dennis Quaid’s case, the use of bar code technology, which also introduced later in the movie, could have prevented the mistake of confusing the heparin and hep-lock. Bar code technology is being used to double check the drug being administered, the dosage, the time of the patient should receive medication, and the patient who will be receiving the medication. Nurses may find themselves in a rush so having this technology at their disposable provides a safety net for the nurse in case there is a mistake that can cause serious damage.
Culture of Safety
The most difficult part of creating a culture of safety would be implementing the change and making sure the employees are following the new safety protocols. This can be a challenge especially if workers are used to a certain way of operation. For example, if nurses are accustomed to keeping physical records for patients and have no experience with imputing the information into a database, it takes time and effort to teach all employees how to do so. Once workers have found their “flow” of working a certain way, it is difficult to change certain habits. Employees would then have to worry about attending to their patients but at the same time learning different skills that are different from what they started with. It may result in frustration and stress in the workplace. Despite such obstacles, there are always going to be changes in the healthcare system because of research that is constantly evolving. Because of this, providers are expected to be progressive and improve their systems as new research comes along.
Inter-professional teamwork is vital to creating a culture of safety and improving quality care for patients because it helps to establish better communication and establishment of trust between all physicians and nurses involved. If physicians fail to exchange information between each other, details are often times forgotten or overlooked. In Chasing Zero, the death of Sue Sheridan’s husband, Cal, could have been preventable if there was inter-professional teamwork involved. The MRI results showing Pat had cancer were misplaced and were never reviewed by the surgeon until six months later. As a result, the mass grew so large that the attempts to remove the tumor became impractical because only a year and a half later after his second surgery, his cancer came back, paralyzing him. If the pathologist contacted the surgeon to discuss the results of the MRI, surgery could have happened sooner and Cal could have lived. Instead, the results remained overlooked and ignored until improvement for Cal became impossible.
In most of the QSEN Competencies, inter-professional teamwork is the most common, underlying theme found. Patient-centered care, teamwork and collaboration, quality improvement, and safety all involve inter-professional teamwork in one way or another (QSEN.org). A large factor that contributes to the success of inter-professional teamwork is communicating between one another. Communication is important in improving the quality of care and safety in the workplace because it is difficult to make improvements when employees are working solely on their own with no regard to the other people involved. Physicians and nurses have different knowledge about the patient since their interactions with them are different. Collaborating with the others involved in the patient’s treatment closes the divide between professions, helps produce better patient outcomes, and reduces the risk of errors that occur.
Conclusion and Discussion
The principle that I will take away from the film Chasing Zero and the QSEN Competencies discussed in this paper is that patient safety will always be the top priority. A profession such as nursing requires one to advocate for improved patient safety and for better patient outcomes. I also acknowledge that though there are systems that appear to be well-established, there is always room to improve and always a way to improve patient care, whether it be in communication or the use of technology in the workplace. The establishment of QSEN Competencies gives nursing students and the occupancy of nursing the guidelines needed to provide successful care to the patient. These six Competencies help reduce hazards such as human error and work to improve healthcare as a whole. The film helps future nurses realize the potential dangers of the workplace and shows the importance of always being aware and conscious of one’s surroundings because there are times when an individual’s life is in your hands, being unaware can put oneself and the patient in danger. Individuals like Dennis Quaid, Sue Sheridan, and Julie Thao are all inspirations for the improved patient safety movement. Though victims of faulty patient care and flawed systems, they all use their platforms to bring awareness to a problem that has not been discussed enough. With QSEN Competencies and consistent advocacy, the goal reducing medical errors to zero becomes attainable.
QSEN Competencies. (n.d.). Retrieved November 26, 2018, from