Nursing Disasters: It’s the Small Things

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Nursing disasters often snowball from small mistakesDuring a recent commute, I caught an episode of WGBH’s and PRI’s “Innovation Hub” that focuses on the way small, seemingly innocuous problems often snowball into massive disasters. As an author and researcher Chris Clearfield points out in the interview, this snowball effect is precisely what disasters like Three Mile Island, Deep Water Horizon, and the 2008 Financial Crisis all have in common. 

In the segment, Clearfield tells the story of a nurse who, while making her rounds, notices that the hospital has put two patients with similar sounding names in the same room. Not only do these patients’ names sound similar, but so do their medications. Clearly, anyone who has worked in, or around, healthcare knows where this is going. 

As the nurse is about to administer the patients’ medications, she realizes she’s about to hand the wrong patient the wrong drugs. Luckily, she catches herself, but this isn’t where true disaster is avoided. 

The nurse doesn’t just correct the problem for herself. She goes on and tells other nurses about what she had just experienced, and as a result, the nurses decide to move the two patients with similar sounding names into two separate rooms. They do this to ensure the nurse on the next shift doesn’t encounter the same problem. 

But the nurses don’t stop there. 

They continue to escalate the problem beyond their team, and the hospital puts a new policy in place to ensure that any patients in the future with similar sounding names would not be able to be placed in a room together. 

Rather than ignoring the small problem and allowing it to snowball, the nurses and this hospital paid close attention to detail and took proactive steps to ensure it wouldn’t turn into a nursing disaster. 

Why Small Problems Like These Get Overlooked in Healthcare

The reason this story struck a chord with me is because, while we might like to believe that any nurse would have acted the way this nurse did, far too often it doesn’t turn out to be the case. 

Consider the current recruitment climate healthcare talent managers are facing. Not only do they have more jobs to fill than ever before, but they’re also facing both a growing skills gap and a nursing shortage. 

On the other side of this equation is a tougher work environment for nurses as well. Some healthcare organizations have more than 600 healthcare regulations to comply with, creating a heaping mound of administrative tasks that pull nurses away from their care responsibilities. Further, these nurses are often overworked and spread thin when it does come to providing patient care, as a full third of hospitals run RN vacancy rates of more than 10 percent. 

Simply put, healthcare organizations are struggling to find qualified nurses for all their open positions — and the ones that they can hire often become overworked and overburdened. 

The fact that the nurse in the anecdote above was able not only to identify and catch the problem from the start, but then appropriately report and follow up on the problem to effect real organizational change, is a testament to the organization’s hiring and development practices. 

So what can a healthcare organization do to ensure they’re hiring and growing the right nurses to provide the exemplary level of care we see in the story above? 

How Healthcare Organizations Can Avoid Disaster Through Hiring and Development

At HealthcareSource, our tagline is, “Quality talent. Quality care.” 

The idea is simple: If you need to improve the quality of care your patients are receiving, the first place to start is with hiring the right nurses, physicians, and allied health staff who work directly with your patients. 

But you also need to go beyond hiring better talent. Once you have the right nurses in place, you need to make sure you’re developing them and growing their careers, so they can help you fill out your leadership ranks and develop new nurses into the quality caregivers your organization expects. 

There are two ways leading healthcare organizations can accomplish this: 

  • Behavioral Assessments: Scientifically backed behavioral assessments are critical to ensuring your organization is hiring the right talent. These assessments help healthcare organizations not just understand whether a nurse’s ability matches the skills listed on their resume, but can also help them understand whether this person will be able to effectively perform their duties once on the floor — and whether or not that nurse has the propensity to stick around an organization for an extended period of time. With behavioral assessments, talent managers can gauge critical thinking skills, attention to detail, leadership qualities, and more. In short, they help healthcare confidently hire candidates who will work in the best interest of their patients and their organization. 
  • Performance Management: The most important part of the nursing anecdote highlighted in the “Innovation Hub” segment is how the nurse was able to elevate the issue once she came across it. This nurse could report it to both her superiors and colleagues, quickly and efficiently, ensuring no other patients would be affected and that the problem didn’t snowball. This can only happen in a healthcare organization that is focused on effective mentoring, coaching, and feedback. When talent managers have performance management in mind, they can put systems in place that make coaching and development easy and fundamental to their team’s success. And, when coaching and development are ingrained in your workforce’s DNA, employees are more likely to be engaged and, therefore, more likely to provide a higher quality of care. 

Transparency Is the Answer

What do Deep Water Horizon and a community hospital have in common? They’re both incredibly complex systems that are run by individuals who often don’t understand the operation’s full scope. While these management systems work in theory, in practice they often conceal small problems that can quickly snowball into disaster. 

But, as Clearfield notes in his interview, “the antidote to complexity is not simplicity — it’s transparency.” 

Hospitals that leverage behavioral assessments in recruitment are looking for transparency from the candidate they’re evaluating, so they can ensure they’re hiring quality talent that can provide quality care. And when healthcare organizations put performance management strategies into place, they’re looking for transparency from their teams, so they can effectively develop their workforces and help them administer even better care.


Admittedly, it’s hard work to weed out all the snowballs in your organization and to prevent disasters like these. But there’s no reason your organization needs to go it alone. Learn more about how HealthcareSource can help you hire, keep, and grow quality talent for quality care today. 


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Salvatore Trifilio

About Salvatore Trifilio

Salvatore Trifilio is a content marketer and former journalist who has written extensively on talent management and technology. Recently, Sal has focused almost exclusively on topics around recruitment marketing, talent acquisition, and employer branding for a wide range of industries and verticals. When he isn’t hammering away at his keyboard, Sal enjoys brewing beer and watching baseball.