Speaker 1: The patient care technician came to me and she told me I need to let you see this screen. She showed me the glucometer.

Speaker 2: She saw the word high flash on the screen and that's what she assumed was the result that she had.

Speaker 1: She's like, I just feel like my blood sugar is really high. She's like, I just feel, I don't feel good. I know my body.

Speaker 3: And so there wasn't really any suspicion that it would be low. And so when this error message comes up, it kind of confirmed that.

Speaker 1: So we rechecked her blood sugar and the same, the same thing popped up. So I covered her with some insulin and I called the physician. And by the time I got her back in bed, she became like non-responsive.

Speaker 2: Ended up being a rapid response and requiring a transfer of the patient to the intensive care unit.

Speaker 3: The nurse had misread the glucometer and called the physician, asked for insulin on multiple occasions and the patient had a severe hypoglycemic event and had to go to the ICU before it was

Speaker 1: caught. During the rapid response, we checked the glucose twice, I believe, and the same thing kept popping up. The screen that said glucose greater than 600. The next day is when I received the call that the whole time her blood sugar was actually critically low.

Speaker 2: Shortly after this particular incident, another nurse made the same error where the machine gave, it was an actual low value, but the machine read off this alert saying for a high, do X, Y, and Z.

Speaker 1: It never came to mind that the glucometer was incorrect. It was probably the worst experience I've ever had in my professional career.

Speaker 2: The nurse manager called our human resources department, said, explain the error. This is what happened. We didn't fully understand the ramifications of this piece of equipment and the message that it displayed. And they said, well, I think you need to suspend her until an investigation is completed.

Speaker 1: I felt like I was talked to like a five-year-old. I wasn't talked to like an adult. I mean, I'm a nurse because I come to take care of people. I come to do my job. I'm very passionate about what I do. And for a long time, it really shook me. Like when I came to work, I was scared to like take care of patients and I was really apprehensive about everything I was doing. I wasn't really confident anymore. It really shook me to the core.

Speaker 2: I questioned it with my boss, and she had the suggestion to invite some of the staff from the human factors engineering department in MI2 to come over and help us at least evaluate the process.

Speaker 4: I got a call from the chief nursing officer at one of our hospitals saying that they had had a case. There was a design issue that might have contributed to the case, and they wanted us to take a closer look at it from a human factors engineering, safety engineering standpoint.

Speaker 3: It quickly became apparent that there was more to the story than just that she had made a mistake, and that there was a lot more, that it wasn't just hers. The actions of lots of people that led to this hazard, and it certainly could happen again.

Speaker 2: You can't fault any one individual. It's a process problem that needed to be addressed, and the more we thought about it,

Speaker 5: the more we decided that we needed to fix the process. The concept of high reliability, the concept of systems problems versus people problems, the concepts involved in human factors engineering, they become very familiar to us, those of us who are talking about them all the time. They're not as familiar to the people on the front lines. Our job is to be able to share that in an effective way, one in which they can actually use the tools and change outcomes.

Speaker 4: The leadership, when they saw our analysis of the case, they supported the fact that Annie should not have been disciplined, and they reversed the discipline, and that was doing the right thing, and I think that sent a very important message to the staff at this hospital, that the leadership supports them and takes the systems approach to managing

Speaker 1: error. They were all sitting there, and they were all nodding, and they were all validating. They were like, okay, so you're not incompetent. Everything you're saying makes complete sense, and it was just like, ugh, it's like I could take a breath and be like, okay, I'm not crazy. And then when I was told by my manager, she pulled me in her office after it, and she was like, we're going to take away the discipline. She was like, they actually said that we didn't treat you so fairly, and that made me feel better, and that was a positive aspect of the experience.

Speaker 4: We need everybody in our system, actually everybody in the healthcare industry nationally, to understand the systems approach, and understand just culture, so that when we have near misses, and when we have small little noticed hazards and unsafe conditions that we encounter day to day in our job, that we report it, and that we look for trends, and where we can, and we fix the system so that the next time that same error or near miss happens, we won't injure a patient.