Making Mistakes into Trainable Moments

2011/08/31 • Comments

Immunization Clinic, ANA PolyClinic, National Military Hospital Campus, Kabul, Afghanistan. Hepatitis B vaccination of nursing student by peer student with advisor team member monitoring procedure. Photo by the Chief Advisor, ANSF Nursing Program.

By Maj. Gen. Peter N. Fuller
U.S. Army Deputy Commander for Programs NATO Training Mission
Afghanistan Combined Security Transition Command – Afghanistan

My Combined Joint Surgeon directorate runs the Afghan National Security Forces nursing program which teaches Afghan nurses. It is taught over three semester timeframes for a total of 61 weeks and teaches student nurses from the Afghan National Army, Afghan National Police, and civilians community to initiate and manage nursing treatments in both fixed medical facilities or in the field. The class is in its third iteration with 45 current students including seven females.

Although accidents are not generally good, there are a number of lessons to be learned when they happen.  For the nursing advisory team, positive strides were seen when a nursing student accidentally stuck herself with a needle contaminated with Hepatitis B.  The AFAMS nursing team acted quickly and advised implementation of a specific 24 hour treatment.

The AFAMS nursing team not only performed life-saving measures on the student, but also discovered deficiencies in the other students’ vaccination records. This discovery led to the procurement and administration of Hepatitis B vaccines to all 45 students. The implementation of this vaccination effort was a combined team effort of ANA and advisor support staff from logistics, pharmacy and the nurse training program. It enabled vaccine to be delivered to 100 percent of the required students within 7 days from incident. 

This team identified several deficits in the immunization program for health care workers in Afghanistan. Student and health care staff immunization records are in the early stages of development. Many records are incomplete, out-dated or missing completely. Many students were found to be either not vaccinated or partially vaccinated due to unreliable vaccine availability and administration procedures. 

The nursing team’s responsibilities include advising nursing program staff how to teach the procedures of vaccination administration to their students. Following this instruction and with supervision, the nursing team had the students perform the vaccination injections. The students were able to refine their skills and learn the policies and procedures for administering immunizations. 

This event also spawned the development of a new AFAMS policy that directs this immunization process and created an enduring solution to ensure the protection of current and future nursing students, staff, and patients from the risks of Hepatitis B, a potentially fatal illness.

Disease prevention and health promotion of the Afghan medical staff and their patients is an enduring mission that will make this country stronger and healthier.


Category: Blog - Leadership, Blog – MG Peter N. Fuller, Blogs - Blogs, News - Medical, News - News

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