' who had worked at the hospital for more than four years, "was an excellent nurse and well-respected and popular with all of her colleagues".
"Everyone is shocked by the loss of a much loved and valued colleague," he added.
Royal College of Nursing chief executive Dr Peter Carter, meanwhile, said it was "deeply saddening that a simple human error due to a cruel hoax could lead to the death of a dedicated and caring member of the nursing profession".'
Jacintha fell victim to a hoax call by two radio hosts from Australia who effectively tricked her into giving out patient information over the phone. She probably believed she was speaking to a relative (the caller claimed to be the grandmother of the patient) but later discovered she had been tricked into giving out patient information. I am pleased to read that Dr Carter describes her action as one of 'human error'. She was working a night shift, was possibly very tired and may have been preoccupied with the many duties nurses start doing around 5 am. There is usually little time to answer phone calls at this point in the shift.
The Australian equivalent of the RCN described the process an Australian nurse would go through after making an error such as this - indeed, the same for English nurses. As a profession, we need to ensure that errors are investigated but the current system does little to ensure that the ' human-ness' of errors is accepted as an integral part of the error.
It was heartening to read that the hospital involved had offered Jacintha support during the ordeal and ensured that her previous hard work and good service record was highlighted. Unfortunately, this is not always the case. The area of error reporting in hospitals is a difficult one. We are assured that incidents and near misses are opportunities for reflective practice and self learning. Errors are also supposed to highlight deficiencies in hospital procedures so that all staff can learn and hopefully avoid the same error. We are told that the error reporting process is not 'punitive' but the reality belies this. Any nurse who has waited up to two years or more for his/her case to be heard by an Investigative Review Board would laugh at the suggestion. Added to the stress of an investigation into practice, some nurses find themselves locked out of employment as a nurse,despite having no restrictions recorded against their practice. An overseas nurse in the position of supporting a family in the UK or in the home country or both may well have no recourse to public funds and panic about the inability to continue supporting his or her family.
There are many reasons why hospital workers make errors. And, here I am talking about genuine mistakes, errors which were not intended. For example,
Tiredness - shift work, working so-called 'long day shifts', working night shifts
Lack of rest time between night shifts ending and day shifts starting - the 'jetlag' feeling
Understaffing -trying to care for too many patients with too little staff
Interruptions during procedures - phone calls, requests by staff,patients or relatives whilst on a medication round or in the middle of a procedure
Personal issues -stress at home, financial worries
My hope is that Dr Carter's words are remembered, that it is ' deeply saddening that a simple human error due to a cruel hoax could lead to the death of a dedicated and caring member of the nursing profession' and that we start to look at the many,many errors, that are being made by health workers and ask ourselves - Why are unintended errors being made by experienced doctors and nurses? Why are so few reported ? What can be done about the hospital culture that prevents errors from being genuinely viewed as learning experiences for a better health system?