Drug errors

MollyJ · Sep 26, 1999

Hi, if you have access to the journal, IMAGE: journal of Nursing scholarship, you should take a look at the current issue (Third quarter, 1999). The journal issue is devoted to health care policy and one article relays an interview of a physician, Dr. Lucien Leape, who now works in the area of dealing with error prevention. I consider what he has to say about error prevention to be a Gadzooks!!! experiece. In essence, he is saying that health care systems should analyze their way of doing things to see how they can be changed to reduce error. Often error is a system problem, not a person problem. Brief quote from Buerhaus's article: "Nursing tends to be locked into double-check and rules approach in which if something goes wrong, then we need a new rule, and when the trouble continues, we need a triple-check instead of double-check. Rules and checks are weak instruments. They have gotten us where we are today. We need to have some fresh thinking to find a better way." He points to unit dose meds as one such preventative.

If you read his article, you may gain a new perspective on your question.

radiann · Oct 11, 1999

I must agree with Molly that we in nursing need to look at the system breakdowns that allow errors to happen rather than the individual in a punitive way. No one is making malicious drug errors and if we track it must be in order to identify where and how errors occur rather than at the specifics of who done it. Additionally rather than apply new rules that just overlay the problem we must get to the root cause of the problem and redesign the system to improve the delivery of medications.

Anthony Marc · Dec 21, 1999

I am not surprised to observed

each of the respondents, including Dr.

Lucien Leape's failure , to recognize an extremely fundamental cause of medication errors: the Human factor. The Human.. to whom the responsibility for the safe administration of assigned medication was given. It is basically misguided to suggest,conclude or identify ANY established procedural entity,relevant to the administration of drugs by a Nurse,as the culprit! If one was truly alert to the realities around oneself as pertains to medication errors... one recognizes, beyond a resonable doubt,that the causative factor

was (to put it simply) the FAILURE one of the Nurse to successfully confirm,satisfactorily, the 5 R's associated with the safe and effective administration of said delivery of the assigned medication.

Punitive: Do you suggest we reward one for

ineffective administration of medications? I suggest one ought to be rewarded with the

reality that, subsequent review which demonstrated, on the part of the RN, a lack of knowledge and/or a lack of an ability to construct logic from

established principles relating to processes of safety, would result in a review of his/her competency by the Licensing Authority. I truly get tired of one always

attempting to find some elusive pseudo-construct toward identify acts of incompetency as a "norm" . It is truly no wonder why such acts continue, given that

type of support.

[This message has been edited by Anthony Marc (edited December 20, 1999).]

diapercity · Dec 26, 1999

I am just a student at this point, however I have noticed at the different facilities I have been doing my clinicals... the nurses are interupted constantly by peers, the patients and family members not to mention a group of students! Coupled with long hours, you would have to be a robot, to function at 100% !

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chrisgidney · Dec 27, 1999

I agree with diapercity. It is my experience that many drug errors are made as a result of an interuption from a third party (infact, the ones that I have been personally involved in have been as a result og just that).

We must never forget that we are each of us, only human, no one is infallible or perfect.

And the question still remains - Do you think nurses' who make a drug error should be punished or not? From my experience nurses' who have made an error punish themselves far more than any other person could ever do.

Regards

Chris

hmt · Jan 20, 2000

I have witnessed a different kind of drug error; what do you think about 'punishment' of this incident (more and more common now)..

I see Nurses that poory spike TPN bags, thus spillage/leakage/waste of the entire bag occurs. What do you feel is a punishment of this med error/incident costing $700-$1200 +

per bag.

jce · Jan 21, 2000

my view on this subject is that when a

nurse passes meds she also has her other

jobs that have to continue at the same

time. the cna's have to be surervised the p

phone has to be answered, the pharmacy

makes their delivery,etc... a med nurse

should just pass meds and the editing

of these meds should be done by a nurse

just doing that one job. if our employers

where that concearned about errors

they could easily make this happen

or regulators in a state could put this

into effect but they don't allow this

to happen .

IrisT · May 21, 2000

Originally posted by chrisgidney:
Do you think that nurses who make drug errors should be punished? Often in the past this has been the case but things are changing (well in my work area anyway). Nurses involved in drug errors often feel bad enough about the whole thing as it is.
Is counselling the best way?
What do you think?
Looking forward to hearing your comments.
Regards
Chris

The only thing nurses learn from punishment is to avoid reporting errors in the future. Because of the punitive systems in effect in some hospitals, not only does the nurse in question avoid reporting, so do all of her co-workers. The systems approach suggested by the ISMP (Institute for Safe Medication Practices)looks at the whole picture and the systems that "set up" the nurse.

chrisgidney · May 21, 2000

I agree with you Iris.

It is my expereince also that most nurses would not, having made a previous error and been disciplined in the past, report drug errors. This is sad because the cause of drug errors will never be fully researched. I feel that a common factor is being distracted whilst giving out medicines by patients, relatives, telephone and colleagues.

Nancy1 · May 21, 2000

Med errors will be made, a nurse who says she has NEVER made a med error has not done a med pass. We need to work with each other and counsel to reduce the risk of it happening again. I do not understand those who want to punish because it will (as said by others) to not reporting med errors. NA

oncnurse · Jun 19, 2000

Originally posted by Nancy1:
Med errors will be made, a nurse who says she has NEVER made a med error has not done a med pass. We need to work with each other and counsel to reduce the risk of it happening again. I do not understand those who want to punish because it will (as said by others) to not reporting med errors. NA