Peer Review questions

  1. I'm sorry this will be long. I am having some questions about the peer review process.

    I just finished a 12 week orientation in my hospital's ICU. On my 4th week I had a med error where I incorrectly programed a bolus of propofol for a patient on the vent that was becoming agitated. I thought I was administering it in mgs, when I was really administering it in mgs/kg -- much, much more than what I was trying to give. I found this out when pt's BP decreased, from fairly normal 100-120s/60-70s to the lowest at 79/30s-40s (sorry, I don't have the exact numbers in front of me). The monitor alerted me to the change in VS, so I immediately checked her Propofol and realized that, even though I'd started the bolus several minutes ago (going to have to look back through the whole chart to see exact time frame), the bolus was still infusing. I immediately stopped the propofol and either restarted or increased the pt's pressor (sorry for fuzzy details, it's been 8 weeks, but I do know that I brought the BP back to systolic 100 within 10-15 minutes). Immediately after changing the medications, while waiting for a few minutes to pass to recheck VS, I informed my preceptor. She and I talked about what happened. I had not yet previously given a Propofol bolus but had known that it was an option to do because I had seen her give at least one of my previous patients a bolus of propofol. I thought I knew how to program it in correctly but this situation showed that I obviously did not. I have given several boluses of propofol since then on other patients and have done it correctly, if not hyper-vigilantly.

    This happened right before shift change. After stablizing the patient, I told the oncoming nurse what happened and let her know why the Propofol was stopped even though pt was having intermittent agitation. We figured out together how much propofol the patient received and I didn't leave until VS were back WNL. Ultimately there was no long-term poor outcome to the patient but I am completely aware that things could have gone VERY differently.

    I was notified that this situation was reported ~3-4 weeks after it occurred (I have no ill will towards the night nurse for reporting it, it was a legitimate error and I learned a lot from it). During one of our standard meetings with my new supervisor and my preceptor, the supervisor asked about it and we told her what happened. Orientation continued on as usual.

    Last week I finished out my last week of orientation and met again with my supervisor (preceptor absent due to illness). Towards the end of the ~45 minute meeting she said that she did need me to make a statement for her as the situation will go to Peer Review in a couple months. She told me about how if this situation, upon review, is still considered a Level 3 (standard of care not met with potential harm to patient), then it can go on to the board of nursing. She didn't seem particularly concerned about it, saying she thought the most that would happen either way would be to get assigned further education (which I'd be fine with -- I'm soaking up as much education as I can). She said to make sure to include in my statement that I was on my orientation. She will take the statement and read it for the review board, I am not to be present.

    Has anyone else been through this process? Since the mistake happened 2 months ago and I'm aware that the patient is fine and long ago went back home, I have to admit that I'm very nervous for *myself*. I really pride myself on being a thorough, conscientious nurse (though obviously with much to learn in this new setting) and the error itself was quite a wake-up call that has really made me even more careful with new medications, especially boluses. Having my statement read before a review board so much later after I've already made 3-4 months of changes (review is in November) is anxiety-provoking. My supervisor's calm demeanor about this is comforting but it does make me wonder if maybe I'm missing something here -- what is the worst-case scenario here? Should I be notifying a lawyer? I'm so naive to this type of thing, I've known OF the peer review board but never known anyone to openly talk about being a part of the process. Though I logically understand that this is just "a step in the process" to keeping all patients and nurses safe, I'm also in uncharted waters and feel like I'm walking around with the word "unsafe" tattooed on my forehead. *sigh*

    Does anyone have any insight?
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  2. 14 Comments

  3. by   Here.I.Stand
    I don't have any first- or secondhand experience with this, but I'm sorry this is happening. By taking a punitive approach, they are discouraging self-reporting. Why would a nurse intentionally jeopardize her livelihood?

    You will never ever make this mistake again. Propofol is a relatively "good" med to make an error with, since it is so short-acting. I have had patients' BP drop to similar levels even with proper administration; they had either come in dehydrated or were more sensitive to the drug than typical. But the BP recovers quickly (assuming that THE cause was the drug). Heck my own BP dropped to 60/30 after getting an epidural, recovering with an extra 1L bolus. You didn't harm the patient, and you clearly learned from this.
  4. by   Wuzzie
    I agree with the above poster. Going to peer review seems a bit heavy-handed. Pump programming errors are extremely common and ridiculously easy to have happen. The advent of "smart" pumps has helped but they are still only one layer of security. My best advice to you is to remain neutral in your explanation of what happened. Try not to place blame on anyone or anything including yourself. By that I mean don't call yourself an "idiot" or say you were "stupid". Stick to the facts and always, always have a plan on how to improve your performance. If I was sitting on your review board I'd also be including your preceptor in the process but I would be hard pressed to send either of you to the BON for a simple human error with no mal-intent. When I was working in ICU we had a policy that anytime a bolus of a potentially risky medication (sedatives, pressors, potassium, calcium) was given via the pump the rate was checked with another nurse. This extra step took just a minute more and was one more layer of security. Sorry this is happening. From your post you sound responsible, level-headed and like you've learned an important lesson that you are applying to your nursing care.
  5. by   blondy2061h
    It seems odd to me that it wasn't even reported until a month after it happened. Do you know who reported it? Be careful around them.
  6. by   JKL33
    I am not familiar with this process but I suggest you Google "[Name of State] Nursing Peer Review" and see what you come up with. If this process is part of your BON regulations, you should be able to find specific information on your rights.

    I hope others who know more will come along to advise you because I'm not so sure you shouldn't talk with a lawyer about this. Your manager has thrown out the possibilty of this being reportable to the BON. Whether we agree with that or not, that's what she said. Minor matters can become subject to others' opinions and interpretations. For instance, if BON reporting is necessary if the PRC finds that you weren't "conscientious" (vague, matter of opinion), then problems are possible. I just think you need more facts. You need advice about writing your statement (which becomes PRC documentation that will be forwarded to the BON if the committee feels this is reportable) and also advice about the fact that she told you that you could not (or shoud not?) appear before with the committee. You may have rights related to things like this.

    I'm very sorry you must practice in such an environment. Maybe I'd feel differently if I was "raised that way" in my nursing career, but from my vantage point, I wouldn't do it. I find it incredibly demoralizing, unproductive, and unsafe for patients - since it certainly invites even "good" people to not tell anyone about situations they think they can manage/fix without telling.
  7. by   Ddestiny
    Quote from Here.I.Stand
    I don't have any first- or secondhand experience with this, but I'm sorry this is happening. By taking a punitive approach, they are discouraging self-reporting. Why would a nurse intentionally jeopardize her livelihood?

    You will never ever make this mistake again. Propofol is a relatively "good" med to make an error with, since it is so short-acting. I have had patients' BP drop to similar levels even with proper administration; they had either come in dehydrated or were more sensitive to the drug than typical. But the BP recovers quickly (assuming that THE cause was the drug). Heck my own BP dropped to 60/30 after getting an epidural, recovering with an extra 1L bolus. You didn't harm the patient, and you clearly learned from this.
    Thank you for your supportive comment. I was nervous to post about this. And you're right, there are definitely worse meds that could have been part of an error. I'm so glad that things turned out so well for the patient.
  8. by   Ddestiny
    Quote from Wuzzie
    I agree with the above poster. Going to peer review seems a bit heavy-handed. Pump programming errors are extremely common and ridiculously easy to have happen. The advent of "smart" pumps has helped but they are still only one layer of security. My best advice to you is to remain neutral in your explanation of what happened. Try not to place blame on anyone or anything including yourself. By that I mean don't call yourself an "idiot" or say you were "stupid". Stick to the facts and always, always have a plan on how to improve your performance. If I was sitting on your review board I'd also be including your preceptor in the process but I would be hard pressed to send either of you to the BON for a simple human error with no mal-intent. When I was working in ICU we had a policy that anytime a bolus of a potentially risky medication (sedatives, pressors, potassium, calcium) was given via the pump the rate was checked with another nurse. This extra step took just a minute more and was one more layer of security. Sorry this is happening. From your post you sound responsible, level-headed and like you've learned an important lesson that you are applying to your nursing care.
    Thank you. You're right, I've learned a huge lesson here and I'm much more careful with my medications boluses and new meds I'm not as familiar with. In our unit during report we often will say things like "pt has Propofol hanging at 40 per hour" without addressing the specifics of the dosing so I'm making myself more familiar with not only the drugs and their methods of action but also their standard dosing.

    Thank you also for your recommendations for how to proceed with my review. I do plan to use the neutral stance ("just the facts," no emotional ties, etc) in my statement. Luckily we get plenty of practice with that in everyday charting. =)
  9. by   Ddestiny
    Quote from blondy2061h
    It seems odd to me that it wasn't even reported until a month after it happened. Do you know who reported it? Be careful around them.
    I believe that it was reported the same day, and that the report was not followed up on by my supervisor until several weeks later. My supervisor apologized for "taking so long to get to the PEARLS" which is our "safety incident" reporting system. So it sounds like there was at least one other that was a bit delayed. I am assuming that the oncoming nurse reported me, since she and my preceptor were the I spoke to it about.
  10. by   Ddestiny
    Quote from JKL33
    I am not familiar with this process but I suggest you Google "[Name of State] Nursing Peer Review" and see what you come up with. If this process is part of your BON regulations, you should be able to find specific information on your rights.

    I hope others who know more will come along to advise you because I'm not so sure you shouldn't talk with a lawyer about this. Your manager has thrown out the possibilty of this being reportable to the BON. Whether we agree with that or not, that's what she said. Minor matters can become subject to others' opinions and interpretations. For instance, if BON reporting is necessary if the PRC finds that you weren't "conscientious" (vague, matter of opinion), then problems are possible. I just think you need more facts. You need advice about writing your statement (which becomes PRC documentation that will be forwarded to the BON if the committee feels this is reportable) and also advice about the fact that she told you that you could not (or shoud not?) appear before with the committee. You may have rights related to things like this.

    I'm very sorry you must practice in such an environment. Maybe I'd feel differently if I was "raised that way" in my nursing career, but from my vantage point, I wouldn't do it. I find it incredibly demoralizing, unproductive, and unsafe for patients - since it certainly invites even "good" people to not tell anyone about situations they think they can manage/fix without telling.
    Thank you for your support. I don't have a problem with being reported, or even having people review the issue if it were to help add some new level of safety (new popups on the pumps, more education, whatever), but I'm definitely stressed about the potential for the BON being involved. I know I have a little time and I'm definitely considering at least speaking with a lawyer that is more familiar than I with these things. I've carried professional liability insurance for the past 5 years, I'm sad to potentially need to invoke its benefit but I suppose that is what it's for. =/
  11. by   TriciaJ
    The BON is mainly interested in safe practice. The error happened two months ago; it was known about right away, not covered up. And the hospital let you keep on practicing in their facility for another two months, during which time you did not make any other errors. Now they are so worried about your safe performance that they need to report it to the Board? Not without making themselves look bad.

    You committed an orientee error, reported it, learned from it and moved on. I can't see the Board being interested in this. I think the hospital just has to jump through hoops for transparency purposes. So just write up how the error occurred, what you learned, how you've adjusted your practice. Like a PP said, no need to assign blame or engage in mea culpas.

    Actually, hospitals and units get dinged when there are no errors reported. It's assumed a certain number of errors happen and if none are reported, then they're being covered up. You've given the hospital a chance to show TPTB that it's on top of things. They owe you one.

    And of course, thank goodness the patient suffered no ill effects.
  12. by   Ruby Vee
    Quote from Ddestiny
    Thank you. You're right, I've learned a huge lesson here and I'm much more careful with my medications boluses and new meds I'm not as familiar with. In our unit during report we often will say things like "pt has Propofol hanging at 40 per hour" without addressing the specifics of the dosing so I'm making myself more familiar with not only the drugs and their methods of action but also their standard dosing.

    Thank you also for your recommendations for how to proceed with my review. I do plan to use the neutral stance ("just the facts," no emotional ties, etc) in my statement. Luckily we get plenty of practice with that in everyday charting. =)
    It seems that you've learned from your mistake, and by sharing it here you've potentially helped others learn from it as well. I don't have anything to add to the advice you've already received, but I did want to say "Well done." We all make mistakes -- it's what you do after you've made the mistake that separates the good nurses from the bad.
  13. by   VaccineQueen
    Keep in mind, even if this does somehow go to the BON, it is their job to investigate all complaints. Just because something is sent to the BON doesn't mean that something will come of it. Like a previous poster said, if the hospital did report that, it would look weird on their part because they kept you employed after the incident. If a nurse was so dangerous to warrant a report to the BON, then it should have been done immediately and firing should have happened. I don't see that in this situation from what you are saying here.
  14. by   Ddestiny
    Thank you again to everyone for the continued support. I've been "offline" for a few days but wanted to provide a small update. After reading TriciaJ's comment...

    Quote from TriciaJ
    Actually, hospitals and units get dinged when there are no errors reported. It's assumed a certain number of errors happen and if none are reported, then they're being covered up. You've given the hospital a chance to show TPTB that it's on top of things. They owe you one.
    ....it helped me to change my perspective a little. I had fallen into a bit of a "what is going to happen to me" anxiety and was having difficulty seeing past it. But this somehow helped to....I don't know, "normalize" the process a little. It made me feel comfortable enough to reach out to a former boss who is not only an experienced nursing supervisor (love my current one to death but it is a new role for her, not much more experience in it than I have in the ICU) but also has a J.D. and has worked in nursing Risk Management at my same hospital, so she's quite familiar with this process. She walked me through the specifics of the different standards of care (and agreed that my error would be a Standard of Care 3 -- standard of care met with real or reasonable potential for harm to patient). Anything that is a Standard of Care 3 or 4 (4 being drug diversion, extreme recklessness or intentional harm to patient) have to be reported to the BON. It's a long, drawn-out process but for things that are Standards of Care 3 the expectation is that any "punishment" will be an assignment of further education (i.e. 6 hours of CEUs r/t sedation, 4 hours of education by someone within the company, etc). There is not a risk to the license like there is with Standards of Care 4 situations, and thus no lawyer is necessary. She offered to read over my statement (without patient identifiers of course) prior to having it submitted to my boss to go to the review board.

    I can't speak to the process for other states (I'm in Kansas), but...well, this is something I can live with. I made a mistake, one that did have the potential for long-lasting harm (my former boss did say that making the BP go into high 70s/40s is still technically "harm" even though we, in the ICU, are fairly accustomed to these numbers). I have no problem with additional education; as I've said I'm seeking it out already; going to an expensive symposium in Critical Care and Trauma next month, I make it a goal to listen to ICU lectures online at least 3 of my 4 days off, I'm starting the ECCO (Essentials of Critical Care Orientation) online education this week, and have attended/am scheduled to attend all of the additional ICU required classes (Basic dysrhythmias, 12 Lead EKG, CRRT, Hemodynamics, IABP, ACLS, etc). Education is my friend! lol

    Thank you again for the kind words. It really helps to hear others say "it's okay to make a mistake". Obviously we want to avoid them at all cost but eventually something will slip through. I didn't realize how "common place" this process was, and you all really helped me to prepare to do this with a level head and eyes wide open. =)

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