Running head: Lateral Violence Leads to Fatal Medication Error

Lateral Violence Leads to Fatal Medication Error

Bobbie Chahal
California State University, Stanislaus
November 4, 2014

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

Lateral Violence Leads to Fatal Medication Error

As defined by The Joint Commission Organization (1996), a sentinel event is an incident
that entails a death of serious physical or psychological injury, or the risk thereof (p. 2). A
sentinel event requires investigation and action to prevent the event from recurring (1996).
Working closely with a vulnerable population, nurses serve as patient advocates, yet are also at
risk for abusing their autonomy that comes with their practice. Lateral violence amongst nurses
in particular, is an example of a reoccurring practice that creates a dangerous healthcare
environment with an increased risk of medication errors. Healthcare institutions must develop
a plan that not only satisfies The Joint Commission (TJC), but also protects the patient
population from errors that occur as a result of disruptive behaviors by nursing staff, so
that sentinel events involving harm to patients can be decreased.
Reviewable Sentinel Events
The Joint Commission (2014) clearly outlines a reviewable sentinel event as:
an event that causes an unforeseen death or lasting loss of function which is irrelevant to
the patients ailment or an event that might not cause death or lasting loss of function, but
does involve suicide, unforeseen death of a full-term infant, abduction of a patient,
discharge of an infant to the wrong family, rape, a hemodynamic transfusion reaction that
involves the administration of a blood product that is incompatible with the patients
blood, surgery on the wrong site/patient/wrong surgical procedure, leaving an object in
the patient after a surgery or procedure, extreme newborn hyperbilirubinemia, excessive
dosage of radiotherapy or to the wrong body part. (p. 3).
The sentinel events described are to be followed up with a prompt investigation by the
responsible institution. The institutions investigation must analyze the causes of the sentinel

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

event and then must propose and execute an action plan to eliminate preventable causes. There
must also be an evaluation of the outcome of the action plan. With such a clear cut set of
guidelines given to define what a reviewable sentinel event is, there are no gray areas that might
interfere with starting the process of investigation and creating changes when a sentinel event
occurs. It is an advantage, in any field, to be prepared before an emergency strikes and The Joint
Commission helps provide the guidance to lead healthcare institutions towards the right direction
before the need arises.
Horizontal Violence
The sentinel event occurred at Basin Medical Center on the Medical-Surgical floor during
the night shift. Tommy Pickles was a newly hired Registered Nurse (R.N.) completing the first
month of a six month long employee orientation. For this particular days orientation, Tommy
was to be under the supervision of Mark Thomas. When Tommy found out who he would be
working with for the day, he became anxious, because every time Mark Thomas worked on the
same shift as Tommy, Tommy would overhear Mark gossiping with the other nurses about how
slow and stupid Tommy was and how he would not ever be a competent nurse. The
unprofessional behavior towards Tommy continued throughout most of the previous shifts.
Tommy decided to give Mark Thomas no opportunity to complain and to impress Thomas so
much that Tommy would be given a chance to prove that he was capable enough and that he
deserved to be respected, not bullied. Tommy became quite busy attending to several of the other
patients, but he continued to perform the six rights of medication administration and performed a
thorough assessment for each of the patients. The last patient under Tommys care was a man
who was the victim of a gang attack at a bar. The patients pain relief was being managed with
several orders of a variety of analgesics. One of the analgesics was Morphine. The patient rated

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

his pain with a seven. The order for that pain level was for two milligrams of Morphine every
four hours, for a severe pain level of seven to ten While he was performing an assessment of the
gang violence victim patient, Tommy heard Thomas snickering to the other nurses at the nurses
station about how Tommy was so slow and how he was wasting time doing unnecessary tasks
when any capable nurse would be finished with the medication pass by now. Tommy became
embarrassed, and felt like he was failing to impress Thomas, so he decided to quickly give the
patient the Morphine so he could be done with his first rounds of the night. In a hurry, he forgot
to ask for a co-sign on the amount of Morphine he was giving. Something to be noted is that the
hospital required that orienting nurses and nursing students follow strict rules for every
medication administration; one of the rules was required co-signing of opioids by the orienting
nurse. Tommy gave the Morphine through the peripheral intravenous device on the right
antecubital site without looking at the patients heart rate of 40 beats per minute, respirations of
eight per minute, blood pressure of 70/50, and the patients lethargic state. Tommy quickly gave
20 milligrams of medication without performing the six rights of medication administration and
rushed out of the room. Tommy felt so happy that he finished his first rounds so quickly and
began to chart at the nurses station so that Thomas and the other nurses could see that he was
already charting and no longer still making his first rounds. While charting, Tommy realized that
he forgot to get the Morphine co-signed by his orienting nurse, Thomas. Before he could think of
what to do next, he saw several of the night shift nurses rush into the gang violence victims
room. He followed them inside the room and soon realized that he had overdosed the patient.
Unfortunately, the patient did not receive help on time and died from respiratory complications
of the overdose.

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

A team that includes nurses, a physician, and several administrators are assigned to come
up with an action plan using Root Cause Analysis (RCA) to prevent such errors from happening
in the future and to satisfy The Joint Commission with the quality of their investigation and
action plan.
Root Cause Analysis
The RCA teams goals are to find out what happened, why it happened, and what can be
done to prevent the recurrence of the adverse event (Sherwin, 2011). It is important to keep in
mind that root cause analysis does not aim to blame individuals, but rather to eliminate causes of
error so harm to patients is prevented (Sherwin, 2011). In order to accomplish this, the team has
started to gather information and defined the sentinel event. Now, the team will determine causes
and plan risk reduction strategies while using evidence from literature to complete the task.
People
There were two RNs and one patient involved in the sentinel event. Lack of peer support and
communication issues are two of the greatest factors in lateral violence amongst nurses (Iheduru,
2014). Verbal abuse, threatening body language, putting one another down, and passiveaggressive communication are just some of the variables contributing to the communication
issues occurring amongst staff (Iheduru, 2014). On the hospital floors, it is common to witness
cliques amongst nurses, nurse burnout, and gossiping /whining attitudes exhibited by nursing
staff (Doherty & Thompson, 2014). What makes this issue worse is that the newly graduated
nurses already begin their orientation in the hospital with a lack of confidence and are then faced
with a seniority rules culture (Iheduru, 2014).
The patient population is vulnerable and also has alternating goals and priorities than the nurses
(Cole, Wellard, & Mummery, 2014). These two characteristics place patients at risk of facing

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

medication errors as a result of the lateral violence that occurs amongst the nurses. First, patients
are not educated in healthcare and are also sick/sedated during their stay (Doherty & Thompson,
2014). Second, they may blindly trust the hospital staff and may feel too powerless to attempt to
muster a voice against the lateral violence in the hospitals (Doherty & Thompson, 2014). In
addition, the patient population is preoccupied with getting discharged and may turn a blind eye
to any bullying witnessed during their stay (Cole, Wellard, & Mummery, 2014). Finally, patients
may want to remain on the good side of the staff and so might divert their focus on other aspects
of the hospital when interacting with administrators or healthcare staff (Cole, Wellard, &
Mummery, 2014).
Environment
The environment also plays a part in allowing lateral violence to continue. There is an
overall lack of time reported by healthcare professionals across the board (Lambrou, Merkouris,
Middleton, & Papastravrou, 2014). Peers are busy, administrators are busy, there is an overload
of charting, the patient to nurse ratio is above the standard, and new nurses are still learning time
management (Iheduru, 2014). Frequent interruptions throughout the day are common and further
worsen the problem (Lambrou, Merkouris, Middleton, & Papastravrou, 2014). There is an
overall lack of privacy which does not allow for the bully and victim to come to a resolution.
There are spectators of the lateral violence who potentiate the issue by gossiping about the latest
maltreatment of another staff member (Lambrou, Merkouris, Middleton, & Papastravrou, 2014).
Lastly, nurses are unable to avoid the presence of family members of their assigned patients, and
privacy to resolve bullying becomes difficult (Lambrou, Merkouris, Middleton, & Papastravrou,
2014).
Management

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

Without any supervision of staff relations, the lateral violence continues to prevail.
Leadership is required so that quick disciplinary action can be taken when an event of bullying
arises. Leadership must also have concern for staff relations, not just when it comes to patient
satisfaction, but also when it concerns how the healthcare team is functioning with one another
(Duffield, Roche, Blay, & Stasa, 2011).
The impression that management gives to the staff is that the management is not
available to deal with complaints not relevant to its agenda (Duffield, Roche, Blay, & Stasa,
2011). Management does this by not being present physically on the floor and when members
from management are on the floor, they carry themselves with a body language of superiority
and choose to come to the floor mostly when there is a time of sharing new rules or reprimanding
staff (Duffield, Roche, Blay, & Stasa, 2011).
Methods
The lack of experience of newly graduated nurses, and the new set of policy and
procedures the new nurses must learn, put new nurses at risk of feeling inferior in relation to
their peers (Agyemang & While, 2010). Additionally, veteran nurses might not be following the
six rights of medication administration and might not be concerned about doing their duty of
supervising the orienting nurse they are assigned with (Agyemang & While, 2010). In regard to
the newly graduated nurses, the hospitals equipment, charting system, floor set-up, and lack of
rapport with the charge nurse/pharmacists might make it difficult for them to look for
guidance/reference when questions arise (Agyemang & While, 2010).
Action Plan

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

The RCA team will then move on to creating an action plan based on Lewins Change
Theory (Schriner, Deckelman, Kubat, Lenkay, Nims, & Sullivan, 2010) and evidence from
literature. Lewins Change Theory has three parts that are part of an ongoing cycle.
Unfreeze
First, the theory requires the targeted population of the change to unfreeze. This
unfreezing involves the target population to become motivated to change. In other words, the
population must no longer resist. Second, the targeted population must then change. This
changing involves the population to take action to bring about the proposed change into reality.
Lastly, the target population must refreeze. The refreezing process requires all of the actions
taken to bring about the change to become permanent (Schriner et al., 2010). In other words, the
target population must accept this new way of thinking/doing things as the correct way and so
this change becomes one that lasts until the cycle begins again in the future for a different
change.
The action plan will begin by unfreezing nurses. In order to motivate nurses to want to change
their attitudes and stop lateral violence, the RCA team will create cohesiveness amongst the
nurses. Using innovative strategies on motivating staff to change the unit environment,
shielding will be the first exercise practiced by the unit (Henderson, Schoonbeek, & Auditore,
2013). The exercise will begin with the staff getting coached on how to listen for concerns while
talking to others and to volunteer help and come to their peers aid in situations in which their
peers were experiencing threats. The nurses were instructed to practice shielding by standing
next to their peer whenever the peer was targeted negatively or threatened. This exercise
gradually will build team cohesion and nurses can feel a sense of unity and perhaps the negative
atmosphere which results from lateral violence will decrease (Henderson et al., 2013). The

LATERAL VIOLENCE LEADS TO FATAL MEDICATION ERROR

awareness will be created by holding various short meetings that require nurses to read and act in
lateral violence case studies (Iheduru, 2014). By doing so, old nurses will feel the pain of new
nurses and new nurses can have a sense of satisfaction in that their pleas for help against lateral
violence are finally being taken seriously (Iheduru, 2014). In order to transition to the changing
phase, role playing in the case studies can help nurses from all kinds of backgrounds assess their
own reactions and biases in the issue of lateral violence (Iheduru, 2014). Nurses can also learn
how to respond to bullying and harassment in these meeting during the role plays and
discussions (Iheduru, 2014). To refreeze the nurses, evaluations will be done every three months
to interview nurses randomly and ask them to describe the positive outcomes they have
experienced on the unit related to lateral violence. The RCA team will use positive reinforcement
to encourage nurses to continue to prevent lateral violence from prevailing in their respective
units.
Next, the plan moves on to unfreezing the environment that lateral violence thrives in. In
order to do so, the RCA team must teach both unit management and nurses on the unit about the
exact conditions of their unit and how it impacts the care being given to patients. An interesting
statistic that can be brought up is that the quality of nursing care is significantly related with the
environments of hospitals that nurses work in. According to Lambrou, Merkourius, Middleton,
and Papastravou (2014), the nurses in favorable environments are 30% less likely than nurses
with poor work environments to report that the quality of care is poor or fair as opposed to good
or excellent (p. 315). Basically, the management and nurses must be guided to appreciate the
value of a good work environment and the impact it can have on the quality of patient care
(Doherty & Thompson, 2014). Follow ups to find out how well both groups are refreezing in

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their attitude towards a good environment will be held at the same time as the randomized
interviews of nurses and management.
Management will be the next focus for the unfreezing process. Based on research, there
are five traits that gain positive leadership scores for the unit managers. According to Duffield,
Roche, Blay, and Stasa (2011), a good manager is a good leader, consults with staff on daily
problems and procedures, flexible, visible and accessible to staff, and offers praise or recognition
for a job well done (p. 29). By letting unit managers know that there are actually a set of traits
they can aspire to accumulate in their work, the unit managers can have tangible goals to meet
instead of not knowing what nurses on their units expect of them. In order to check for the
refreezing of the managers, random interviews will be conducted. In addition, managers will also
go through role play to practice techniques on how to deal with nurses who keep up the lateral
violence in the units.
Change
The RCA team will tackle the methods or procedures of the unit. In order to change
nursing practices that do not follow the policy and procedures of the unit, there needs to be a
system of continued education in the unit (Agyemang & While, 2010). This continued education
will be initiated with a minimum of five peer communication sessions held by a nurse educator.
These sessions will be once a month and will cover techniques, discussion, role-play, time for
questions and answers, refreshing information, rewarding those that are changing, and finally,
evaluating the unit. Policies such as checking the six rights of medication administration or
procedures such as the co-signing of medication administrations need to be reviewed regularly to
keep the rules fresh in the nurses minds as they start their shift (Agyemang & While, 2010).
Charge nurses must be available to help out whenever the nurses on the floor become

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overwhelmed and feel the need to rush procedures. One action that can really help solidify or
refreeze these concepts is the promise of a pot luck or pizza party for the unit whenever goals are
reached that demonstrate that correct policy and procedures are being carried out. Lastly, the
random interviews that will be held can allow nurses to give input on how units can change to
allow the nurses to better perform their jobs in a safe manner.
Refreeze
In order to refreeze, or maintain the changes brought on by the changing process, a nurse
educator (Henderson et al., 2013) will be frequently brought onto the unit to review, reward,
evaluate, and refresh the new techniques learned throughout the transitioning process so that the
changes that nurses make are recognized and encouraged while negative behavior is managed
privately by the unit managers using the chain of discipline which includes a verbal warning,
written warning, and then suspension or termination for those that choose to remain the bullies of
the unit (Radovich, Palaganas, Kiemeney, Strother, Bruneau, & Hamilton, 2011). The rewards
given to exemplary behavior will consist of the placement of the nurses photo on a board titled,
Most Valuable Nurse on the unit, a certificate and a pin.
Target
The action plans goal is to transform the nursing work environment to favor teamwork,
teaching, and respect (Henderson et al., 2013). Nurses, patients, and management are the target
population in this change because all of these members are impacted by the kind of attitude that
is prevalent amongst nurses and some of these members are required to actively participate in
the plan themselves in order to accomplish the change.
Patients

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During the hospital stay, patients meet several nurses, not just one. Each one of these
nurses attitudes affects the kind of care the patient receives (Doherty & Thompson, 2014). With
nurses starting to project a positive attitude that values teamwork, teaching, and respect, patients
will then change their view of nursing as a field of professionals rather than gossiping/bullying
hospital personnel (Doherty & Thompson, 2014).
Nurses are key stakeholders in this proposed change because they are the main
component of the issue of lateral violence in the workplace in the nursing community. Because
nurses must coordinate with so many other members of healthcare, they must prevent the spread
of their own negative attitudes from potentially influencing the rest of the care team.
Additionally, nurses are impacted by other nurses and vice versa when lateral violence is being
practiced throughout the shift.
The nurse educator will be in charge of evaluating, rewarding, reviewing, teaching, and
giving input to the unit managers after every visit to the unit (Henderson et al., 2013). This way,
those that are changing are getting rewarded for their efforts while those that choose to remain
stuck in their ways, will be given disciplinary action (verbal warning, written warning,
suspension, and termination) by the unit manager (Radovich et al., 2011).
Unanticipated Consequences
The RCA team anticipates meeting with many consequences as a result of the actions
carried out to accomplish the goal of decreasing lateral violence in the units. With change, there
could be a force of resistance from the staff. If there are nurses or managers who refuse to
eventually accept and adapt to the proposed changes, there is a potential for the RCA to use
disciplinary actions to make it clear that lateral violence is no longer a tolerated issue on the unit.
In addition, if there is a continued trend of lateral violence occurring and no changes are noticed,

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the RCA will discuss the setbacks with the staff to gain insight in how to better facilitate the
change in the unit. Unfortunately, any plan can fail so the RCA is prepared to start over from
scratch if that is what it will take to improve patient safety and protect nurses from lateral
violence.
Conclusion
In order to accomplish the goal of protecting patients from errors that occur, as a result of
lateral violence, and to also satisfy TJC with an action plan, the RCA team will carry out the
action plan created using Root Cause Analysis and literature. Lateral violence is made possible
with the presence of many variables on the unit. With so many different causes to focus on, the
changes the RCA team hopes to bring to the unit will be transformed into reality with the help of
management and nurses working together.

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References
Agyemang, R., & While, A. (2010). Medication errors: types, causes and impact on nursing
practice. British Journal of Nursing, 19(6), 380-385.
Cole, C., Wellard, S., & Mummery, J. (2014). Problematizing autonomy and advocacy in
nursing. Nursing Ethics, 21(5), 576-582. doi:10. 1177/0969733013511362.
Doherty, M., & Thompson, H. (2014). Enhancing person-centered care through the development
of a therapeutic relationship. British Journal of Community Nursing, 19(10), 502-507.
doi:10. 12968/bjcn.2014.19.10.502
Duffield, C., Roche, M., Blay, N., & Stasa, H. (2011). Nursing unit managers, staff
retention and the work environment. Journal of Clinical Nursing, 20(1/2), 23-33. doi:
10.1111/j. 1365-2702.2010.03478.x
Henderson, A., Schoonbeek, S., & Auditore, A. (2013). Processes to engage and motivate staff.
Nursing Management UK, 20(8), 18-25. doi: 10.7748/nm2013.12.20.8.18.e1150
Iheduru-Anderson, K. (2014). Educating senior nursing students to stop lateral violence in
nursing. Australian Nursing & Midwifery Journal, 22(1), 15.
Lambrou, P., Merkouris, A., Middleton, N., & Papastravrou, E. (2014). Nurses perceptions of
their professional practice environment in relation to job satisfaction: a review of
quantitative studies. Health Science Journal, 8(3), 298-317.
Radovich, P., Palaganas, J., Kiemeney, J., Strother, B., Bruneau, B., & Hamilton, L. (2011). Best
practices in critical care. Critical Care Nurse, 31(5), 58-63. doi:10.4037/ccn2011463
Schriner, C., Deckelman, S., Kubat, M. A., Lenkay, J., Nims, L., & Sullivan, D. (2010).
Collaboration of nursing faculty and college administration in creating organizational

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change. Nursing Education Perspectives, 31(6), 381-386. doi:10. 1043/1536-5026

31.6.381
Sherwin, J. (2011). Contemporary topics in health care: root cause analysis. PT in Motion, 3(4),9
26-31.
The Joint Commission (1996). Sentinel event data: event type by year. Retrieved from
http://www.jointcommission.org/assets/1/18/Event_Type_by_Year_1995 2Q2013.pdf

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17

LBudget for Reducing Lateral Violence

Year:

2014

Organization: Basin Medical Center

Submitted
by:
Bobbie Chahal
Total
Budget:

$4,225

Budget Planning
Line
Item
1 Questionnaire on lateral violence
2 Peer Communication Sessions

3 Most Valuable Nurse board

4 Certificates & Pins

5 Nurse educator

Description/Justification
This questionnaire will assess current
views and input for change.
The sessions will be categorized as
continued education units. These sessions
will include role-playing, discussions,
question and answer periods, and learning
skills that will enhance cohesiveness of the
unit's nurses. (Five thirty minute classes
minimum: $30 per class= $150. 25 nurses
X $150 = $3,750. *Unit cost rate will help
pay for supplies such as writing utensils
and paper
This will display the picture of the Most
Valuable Nurse as evaluated by the nurse
educator and the unit manager. The
educator and manager will take input from
the floor nurses to assess who is making
the most progress.
They will positively reinforce the positive
behaviors of nurses.
Needed to teach, evaluate, review, reward,
and refresh the new changes monthly.
Educator: Five 30 minute classes
minimum, $30 X each class (5 total)=
$150

Qty.
25
25

Unit
Cost/Rate T
$1

$150 $3

$50

25

$10

$150

Grand Total $4

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