Sentinel event

dnptobe20 · Feb 26, 2016

I commend you for wanting to improve your practuce. Here are a few important notes i can think of:

Try to never give a medication without scanning the patient ID band and medication first. This is an airtight way to verify your med 'rights' - especially correct dose and route (if you are only giving a fraction or double etc...)

If med order does not look right to you, STOP and call the doc AND pharmacy to verify med, indication and dose

If you have to give med in emergent situation/ verbal order at bedside verify with at least one other nurse before giving

If you get interrupted while giving meds, stop and take a minute to refocus before continuing to give.

When you set up a high risk infusion that needs a double check, let the second nurse check your order, bag and pump setup independently without you interfering to catch errors. They should also initial on high risk label before you start med

When giving shots have a hyperfocused zen moment when withdrawing the needle from the patient, sheathing/retracting it, and discarding it. This will help to prevent you sticking yourself

When handling narcotics, always try to administer dose as soon as you withdraw (latest within 30 mins). Have another RN verify waste and witness you on pyxis or in pts EMR.

SpEdtacular, MSN, RN, EMT-P · Feb 27, 2016

When you set up a high risk infusion that needs a double check, let the second nurse check your order, bag and pump setup independently without you interfering to catch errors. They should also initial on high risk label before you start med
.

I would add, make sure the second nurse confirming high risk meds is taking the double check seriously and not just cosigning!

Don't give a medication you're unfamiliar with without looking it up first. Otherwise how can you know that your five rights are right? Doctors and pharmacists make mistakes too so don't let yourself get complacent.

The Institute for Safe Medication Practices is a wonderful resource and has lots of excellent information Institute For Safe Medication Practices

Jordym919 · Feb 27, 2016

Thank you so much, I will take these into consideration when practicing! I appreciate the feedback!

Karou · Feb 27, 2016

Everyone else has given some fantastic tips.

I will add, when a patient tells you something doesn't appear correct or is unusual, take a moment to do a second check.

If you ever give a partial dose (like half a tablet), then as soon as that is scanned STOP your process to half that tablet before continuing. Good nurses have forgotten to actually administer a partial else, and have given the entire amount.

When hanging multiple IV medications, always verify that the pump your programming corresponds correctly to the medication. Follow the channel and tubing up to the bag.

Jordym919 · Feb 27, 2016

Thank you! All great advice! I love hearing experienced nurses tips and opinions :)

LeChien, BSN, RN · Feb 27, 2016

Hello I am a nursing student in my last semester of nursing school and will be graduating this upcoming May, I have worked in ICU as an aide for the past three years throughout school. A few months ago our ER had a sentinel event from a med error with a child involved, and since then the hospital has made multiple policy changes with medication administration and pharmacy procedures etc. and still we have had some pretty serious medication errors, not sentinel, but still. I am looking for any advice as a new graduate to avoid theses types of errors, in school you are taught to follow your medication rights religiously but are there any other words of advice for a new grad because medication administration is scary as a new grad and after personal experiences in my own hospital workplace. Thanks!

Can we ask what the sentinel event consisted of?! I'm nosy.

iluvivt, BSN, RN · Feb 27, 2016

Don't blindly trust the pharmacy label. We got a patent transfer recently a nurse had hung some Pitocin on a laboring patient. At least that's what the label said...it was NOT. Patient ended up in ICU..it was some entirely different medication.

NEVER speed up any drip to prime the IV tubing unless the pump has a special prime function. I learned early to never do this but my coworker did not. She sped up a Lidocaine drip from 20 cc per hour to 220 cc per hr to prime the tubing after an IV restart. She forget to turn it back and the patient started seizing once they got toxic levels.

Jordym919 · Feb 28, 2016

A bag of potassium that was meant for an adult patient was given to a child less than a year old instead of the ordered NS... it resulted in cardiac arrest.

Jordym919 · Feb 28, 2016

Very good advice! I feel like trusting the pharmacy label happens all too often.

cupcakeluver · Feb 28, 2016

Great thread Jordym919! I'm graduating in May too, and I often worry about the "real world" of nursing. Looking forward to reading all the great tips. :)

ClaraRedheart, BSN, RN · Feb 28, 2016

Thanks to our scanning technology, med errors should be FEW and far between. As a precaution, all vial meds, I will draw up in the med room, prior to entering the patient's room. I will look at the patient's MAR and verify the dose before drawing up the med and disposing of the rest. Occasionally, I will get a pop up on a med that I did not expect, a half pill that should have been ordered instead of a whole. I cases like these, I keep a spare pill cutter (brand new) in my pocket to leave in that patient's room should there notl be one present. In rare cases, I get that message over pre-packaged syringes like Lovenox. Before scanning any further meds (when I have partial doses) I will find the rest of the med, or dispose of the other part of it. This ensures that it doesn't slip my mind before I admister these to the patient.