Anyone Who Says They Don't is Lying: Medication Error

[BonnieSc]

Like most students, I thought the 5 Rights of Medication Administration were a little... bogus. I wasn't a kid; surely I could be depended on to have common sense. Weren't the 5 Rights almost insulting to nurses? I had been giving medicine to myself, family members, children at the summer camp where I worked, residents at the assisted living facility where I was an aide before nursing school, for years. I never gave Tylenol where I should have given Benadryl or accidentally gave a medicine one hour later instead of four hours later. Certainly I never gave medication to the wrong camper or resident. I relegated nurses who made medication errors to that unfortunate class that includes nurses with substance abuse problems... a category I would never visit.

I made my first medication error (that I know of) in my second semester of clinical, on an oncology unit. My single patient, an elderly man with acute myelogenous leukemia, was ordered for IV Zosyn. I had checked this carefully, made a care plan, wrote down in detail when I was to give the medications. Halfway through the morning, the doctor came through and increased the dosage. I think I was dimly aware of this, had read the order. At the time for the medication, I went to the refrigerator, checked the right patient and right drug. I knew it was the right time and the right route. I told the nurse I was giving the medication now, and she nodded and gestured me away. My clinical instructor was on call if I needed him. I hung the medication for the sweet old man without incident.

An hour later, the patient's nurse came to me, holding a bag of zosyn. "Why didn't you give this?" she asked. "I did!" I responded, alarmed and defensive. "Then why is it here?"

We went to the bedside and found the zosyn I had hung. Right patient, right drug, right time, right route... wrong dose. The pharmacy tech had brought the new bag without removing the old one, which had already been prepared. When I picked up the bag from the refrigerator, I didn't notice there were two for that patient, and I never rechecked the dose. I felt cold and hot and nauseated. How could I have done such a thing?

The nurse berated me for not checking properly and began to fill out an error reporting form. I heard her telling the other nurses about it. "Oh, just a student not paying attention," she said with an air of weary superiority.

When she finished making the report, she came to me. "You know your clinical instructor needs to know about this," she said. "I can tell him about it if you want." I sensed an eagerness in her voice. "I'll tell him about it myself," I said, insulted.

I was surprised at how calm my instructor was. I didn't know him well, but from the nurse's reaction, I expected a blowout; possibly a suspension. "Okay," he said. "Do you know why that happened?" I explained that I hadn't checked the dosage. "I don't think you'll make that mistake again," he said. "There's a form you have to fill out for the school, and I think you aren't allowed to make more than two errors, but you're going to be okay." In his record of the incident, the instructor included the line: "To the student's credit, she took ownership of the incident and reported it to me personally."

In my previous jobs, I occasionally had to deliver discipline to employees, and I felt like I hadn't been disciplined enough. I looked at the situation as if I were one of my junior camp counselors, and went to the theory professor with a plan: I wanted to explain to the first semester students what I had done so they would know it can happen. They listened to my experience with interest, although I knew they were all thinking "but I would never do that". Maybe I prevented a few errors. I know I provided an example.

Naturally, I thought this would be the last medication error I would ever make, and to my knowledge, I didn't make any more during nursing school. My first job was at a busy hospital with a high nurse/patient ratio; I usually had 7-10 patients during the day. It was months before I felt like I had time for anything more than running around dispensing medication. One of my friends from orientation made the first medication error in our group. She confessed it to the charge nurse, a woman I had already grown to admire enormously as someone who always knew the right thing to do. "Well, call it in to the reporting line," she said straightforwardly. "We all make medication errors. Any nurse who says she doesn't is lying."

My friend felt better, and I was startled. I had never heard this put so bluntly before. My instructors said it was easy to do, but they never quite got across to me that everyone does it. I filed this line away in my mind.

I've made several medication errors since then. I mixed up a John and a Tom and the IV bags were found by the next nurse-the worst error that I'm aware of committing. (No harm to patients.) I've hung the right antibiotic at the wrong time. I've given whole pills where I should have given half. I've given medications that were discontinued a few minutes previously.

Recently I gave a class on medication errors to a group of students, with examples. "These are all taken from my practice or were done by nurses I know," I said casually. The students were shocked. "YOU did that?" one of them asked. "No, my friend did," I said. Through my years as a nurse, with experience on various committees that look into incident reports, and many late-night confessionals among night nurses, I haven't become immune to med errors--but I have come to understand them as part of nursing life. I'm quite sure I don't make more errors than the average nurse; I hope I make less. I don't usually make the same error twice (the exception being those half-pills-I was relieved when I moved to a hospital where all pills are split in the pharmacy). And I've counseled many students and new graduates through their first medication errors.

And because I've learned that every medication error is a systems error: I report, report, report, and encourage others to do the same.

Learn more from another nurse: "Making Mistakes As A Nurse" video...

anyone-who-says-she-doesnt-is-lying.pdf

[Susie2310]

As for whether a student who makes a medication error should be suspended, I think absolutely not (barring extenuating circumstances; assuming it's a standard sort of error), any more than a nurse should be fired for making one. Medication errors are [supposed to be] reported anonymously for a reason--because they are system errors, or could possibly be prevented by a change in systems. Punitive reactions to medication errors only make nurses go into hiding when they make one.

The point of dismissing students from the program I attended for medication errors was partly to impress upon students that medication administration using the five rights was to be taken seriously, and was not to be regarded as "bogus."

You appear to want to absolve the nurse of individual accountability for medication errors. Medication errors "may" be due to "systems" problems, but are often due to individual nurse errors. Failure to use the five rights to administer medications safely is often not a "systems" problem, but an individual nurse failure. For instance, failing to properly identify the patient at the bedside; failing to confirm patient allergies; failing to verify that the dose of the medication is the same as the physician ordered and is appropriate for the patient to receive at the time of administration based on the patient's current medical condition; administering the medication by the wrong route when the physician has clearly stated the route; miscalculating the dose of an IV push medication and administering the wrong dose; failing to administer a dose of a medication at the ordered time because one doesn't read the MAR correctly, are all individual nurse errors. Of course nurses should report medication errors; but we can be big enough to not blame all our mistakes on "systems" problems.

[macawake, MSN]

Medication errors "may" be due to "systems" problems, but are often due to individual nurse errors. Failure to use the five rights to administer medications safely is often not a "systems" problem, but an individual nurse failure. For instance, failing to properly identify the patient at the bedside; failing to confirm patient allergies; failing to verify that the dose of the medication is the same as the physician ordered and is appropriate for the patient to receive at the time of administration based on the patient's current medical condition; administering the medication by the wrong route when the physician has clearly stated the route; miscalculating the dose of an IV push medication and administering the wrong dose; failing to administer a dose of a medication at the ordered time because one doesn't read the MAR correctly, are all individual nurse errors. Of course nurses should report medication errors; but we can be big enough to not blame all our mistakes on "systems" problems.

(my bold)

Yes and no. Yes, the mistakes you listed are individual nursing errors but the individual's errors can sometimes (often) be hard to separate distinctly from system errors (or suboptimal working conditions).

Constant distractions and interruptions are generally accepted as the norm in healthcare. Research shows that distractions and interruptions contribute greatly to medication errors. The stress of being interrupted while focusing on important tasks can cause cognitive fatigue, resulting in omissions, lapses and mistakes. Added to this is the fact that nurses often have unreasonable workloads/nurse-to-patient ratios and that hardly promotes patient safety. We're not superwoman or superman, we're humans and human beings will make mistakes.

Since medication errors can have very serious consequences we need to actively work towards minimizing the number of errors made. I think that this is best achieved through education, clear rules/routines/protocols and by finding ways to improve our work environment so that it's better adapted/suited to the limitations of our "distraction-sensitive" brains (Yes, I know I just made that term up..)

Yes, we are accountable as individuals but I think that it's important to look at all factors that contribute to the mistakes that are made. If an individual nurse makes more mistakes that "average" or repeats the same mistake, that needs to be addressed. The most suitable intervention likely depends on the individual circumstances of the specific nurses' error/s. However we can hardly terminate all nurses who's ever made a med error. There wouldn't be that many left..

In my opinion (and as already mentioned), an overly punitive approach will only serve to hide errors, not eliminate them. When mistakes are concealed/covered up they become even more dangerous. I think that we need to have an atmosphere where they are openly discussed and learned from.

[NICU Guy, BSN, RN]

I have never heard of a school or hospital that allowed students to give/hang meds without direct supervision. You infer that it was no big deal, no harm done, instructor didn't think it was serious and neither did the nurse. Wasn't it your school and hospital's policy to have the nurse supervise the hanging of the med? Even if the nurse told me to do it without her, I would have been suspended for not following school policy. I understand that the point of the article was to point out that the 5 rights are important, but the additional lesson is that you are a student and should know your scope of practice.

[BonnieSc]

The entire point of my article is that the 5 Rights are not "bogus". My experience with students has showed me that most students (like myself as a first-year nursing student) don't think they're really necessary.

Reporting of medication errors has led to such systems improvements as ID bands, allergy bands, individual dosing, specification of route, precalculated IV medications, and more efficient MARs.

I am the villain of this piece; I have announced my own mistake to a large audience in order to shine a light on medication errors. It's odd that you would read this as me attempting to absolve the nurse of responsibility.

In fact, I only mentioned the "systems error" concept briefly in the last paragraph, mostly because I knew how many nurses would read this and think "but that was a systems problem"; I wanted to acknowledge that aspect. The bulk of the piece is about the importance of the 5 Rights and individual responsibility. Please don't imply that it is about the 5 Rights being bogus and irresponsibility being acceptable.

[benegesserit]

I'm a student and I don't think the 6 Rights are bogus. I do it every single time I administer meds. I know that in the real world of nursing, things will be very different than my protected bubble of clinical, but I'm hoping that I will never make one. I'm too scared of killing someone.

You will make mistakes. If not a med error, something else. Good, conscientious nurses make mistakes, because even the best nurses are human. And, as the OP said, every error is a system error, with multiple contributing factors.

Knowing that mistakes happen and that it doesn't make you a bad person is key to handling mistakes calmly and appropriately.

Most med errors are not actually going to cause any serious harm.

This all isn't to say you should keep a casual attitude towards safety. But assuming that you will make no mistakes because you're careful and not that sort of nurse is a danger in itself.

And yes, in some environments, doing the med pass nursing school/survey perfect, slowly and deliberately checking the 5/6/whatever rights 3 times on each and every med for each and every patients is going to result in "Wrong Time" med errors.

And there are errors that simply following the five rights during med pass won't prevent. I've seen multiple (from myself and others) that would not be prevented by simply following the five rights. Medication changes not recorded in the MAR. Getting distracted between med cart and patient and giving meds to the wrong patient. Giving meds to the wrong patient because the nurse is brand new, the facility doesn't use identification bracelets, the patient has dementia and is unable to respond appropriately, the identification pictures in the MAR were inadequate, and the answer from the staff member who the nurse asked about the patient's identity was unclear. The nurse bears a varying level of responsibility in each of these cases, but there's clearly more than one contributing factor in all of them.

Personally I hate that some schools are now teaching "the six rights"--the sixth right being Right Documentation. Five is enough, five is for patient safety in administration. Yes, we have to document, but that isn't specific to medication safety. Five is easy to remember and has a good mnemonic in the five fingers. " Right Documentation " has just been a distraction to my students.

I can see your point. The more things you have to remember, the more chance that one of them will get missed, and I'm sure it's more about compliance than anything. But documentation really can be important to medication safety. Was this med given or missed? What time did they last get their PRN? If it isn't documented, it may be difficult to tell.

Anyways, I agree with OP - I think a no-blame environment and looking at mistakes as system errors is important for patient safety. Because, when a mistake does happen, you want it to be addressed appropriately and prevented from happening again, not shoved under the rug because of staff feeling they have to cover it up to protect their jobs.

Re: the clinical instructor--practices are different for different schools/hospitals. My memory on this point is a bit vague, but I do think there was a point where the nurse I was working with was supposed to come with me or doublecheck the medication and didn't. Even if that was so, as far as I'm concerned the fault was mine, not hers--her responsibility was on her own conscience. I had been taught the proper procedure and didn't follow it. In that clinical placement, my group of ten people was spread throughout three units in the hospital, and there was no expectation (then or at any clinical placement I can remember) that the instructor checked our meds or was with us when we gave them. I have experienced that with students from other schools as a nurse, though.

This is how it was with my school. After being checked off on giving a certain route of medication, we were allowed to give those meds without our instructor present. And yes, we were supposed to review them with nurse in charge of our patient. Some of them quizzed me harder than my hardest clinical instructor, some took a cursory glance at best.

[BonnieSc]

I have never heard of a school or hospital that allowed students to give/hang meds without direct supervision. You infer that it was no big deal, no harm done, instructor didn't think it was serious and neither did the nurse. Wasn't it your school and hospital's policy to have the nurse supervise the hanging of the med? Even if the nurse told me to do it without her, I would have been suspended for not following school policy. I understand that the point of the article was to point out that the 5 rights are important, but the additional lesson is that you are a student and should know your scope of practice.

This was simply not my school's policy. I think it might have been in pediatrics because of the particular challenges and risks in calculating drug doses there. I do remember being told not to take verbal orders from doctors or verbal delegation on medications from the staff nurses. I'm sorry if my very serious reaction to the incident (absolute horror) didn't come across in the article, but some other responses seem to have picked up on it.

[MunoRN, RN]

Personally I hate that some schools are now teaching "the six rights"--the sixth right being Right Documentation. Five is enough, five is for patient safety in administration. Yes, we have to document, but that isn't specific to medication safety. Five is easy to remember and has a good mnemonic in the five fingers. " Right Documentation " has just been a distraction to my students.

We're actually now up to as many as 14 rights of medication administration.

14 Rights of Drug Administration Flashcards - Cram.com

[Susie2310]

And, as the OP said, every error is a system error, with multiple contributing factors.

Most med errors are not actually going to cause any serious harm.

And yes, in some environments, doing the med pass nursing school/survey perfect, slowly and deliberately checking the 5/6/whatever rights 3 times on each and every med for each and every patients is going to result in "Wrong Time" med errors.

And there are errors that simply following the five rights during med pass won't prevent. I've seen multiple (from myself and others) that would not be prevented by simply following the five rights. Medication changes not recorded in the MAR. Getting distracted between med cart and patient and giving meds to the wrong patient. Giving meds to the wrong patient because the nurse is brand new, the facility doesn't use identification bracelets, the patient has dementia and is unable to respond appropriately, the identification pictures in the MAR were inadequate, and the answer from the staff member who the nurse asked about the patient's identity was unclear. The nurse bears a varying level of responsibility in each of these cases, but there's clearly more than one contributing factor in all of them.

So you are saying that if you, as a nurse, administer a medication that was clearly ordered by a physician to be given by a specific route, by an incorrect route, because you "thought" the order said what it did not in fact say, that is a "systems problem?" Are you going to blame too many patients, someone interrupting you, etc., - there is no end of things in our work environment to blame, so in that sense I suppose they could all be "contributing factors." How about taking personal responsibility? Perhaps looking at one's actual practice of administering medications, and seeing where one can improve. Yes, errors can be caused by systems problems; that has been acknowledged; but not all medication errors are caused by "systems problems."

Some medication errors do, actually, cause serious harm. If you experience a medication error as a patient, or as a patient's family member, even if the patient is not seriously harmed, you may not be so casual about medication errors.

If you fail to check the "five rights" and lack sufficient knowledge of the medication/s you are administering, you will likely have even bigger problems to worry about than failure to give a medication on time.

Yes, of course the "five rights" will not protect you from every possible medication error. That is where the nurse's critical thinking, knowledge of medications, and safe medication administration practice comes into play.

[benegesserit]

So you are saying that if you, as a nurse, administer a medication that was clearly ordered by a physician to be given by a specific route, by an incorrect route, because you "thought" the order said what it did not in fact say, that is a "systems problem?"

Well, if everything was totally clear, what caused me to think the order said one thing when it actually said another?

Sometimes it really does come back to the nurse. In that case, the system failure could be screening of new employees, inadequate supervision, that sort of thing.

Are you going to blame too many patients, someone interrupting you, etc., - there is no end of things in our work environment to blame, so in that sense I suppose they could all be "contributing factors."

Recognizing contributing factors does not mean placing all responsibility for a situation completely outside of one's self. It just means looking at the bigger picture.

Yes, things like too heavy workload, people interrupting, and exhaustion are all factors that can contribute to errors. We can punish the individual nurse, or we can attempt to address the factors that create an unsafe environment. Which is actually likely to help more in the long run?

How about taking personal responsibility? Perhaps looking at one's actual practice of administering medications, and seeing where one can improve. Yes, errors can be caused by systems problems; that has been acknowledged; but not all medication errors are caused by "systems problems."

What part of what I wrote said that the nurse should take no personal responsibility?

Reporting a med error is taking personal responsibility, and takes guts. A no-blame environment simply encourages this.

Looking at your own practice and making adjustments is also a part of it. I didn't mention that, but it's certainly my personal reaction to such situations.

Some medication errors do, actually, cause serious harm. If you experience a medication error as a patient, or as a patient's family member, even if the patient is not seriously harmed, you may not be so casual about medication errors.

I never said they didn't. Yes, errors, medication and otherwise, can cause serious harm. Many don't. Feeling comfortable enough with the possibility of making errors and the reality that errors can happen to anyone facilitates bringing the less-serious errors - the ones easily swept under the rug that no one would ever know about - to light, and helps prevent a possibly more serious issue in the future.

Discussing creating an environment where errors can be addressed, contributing factors identified and rectified, and future occurrences hopefully avoided is by no means taking medication errors lightly.

Going to work, so I won't be responding further tonight.

[Susie2310]

Well, if everything was totally clear, what caused me to think the order said one thing when it actually said another?

Inattention/carelessness.

[Purple_roses]

Personally I hate that some schools are now teaching "the six rights"--the sixth right being Right Documentation. Five is enough, five is for patient safety in administration. Yes, we have to document, but that isn't specific to medication safety. Five is easy to remember and has a good mnemonic in the five fingers. " Right Documentation " has just been a distraction to my students.

I think it's important. What if you don't document a medication and someone else looks at the patient's chart and gives the med, thinking you never did? As a student, I'm a fan of the 6 rights. I am terrified of something bad happening to a patient because of me. I will happily jump through the 6 hoops to help prevent that.

[Purple_roses]

Also would like to add that I appreciate your transparency OP. I think your honesty probably sets your students at ease.