Drug errors

ICUNurse · Jul 4, 2000

Originally posted by JillR:
ICUnurse,

I don't quite understand the problem here. We administer potassium all the time throught periphereal IV's. We use liter bags though. Is it the concentration of the potassium thats the problem? Sorry but I just want to get this straight. I am assuming that the concentration of the potassium is irritating to the veins? Could you please enlighten me. Thanks. JillR

In the ICU I work in, we also give potassium peripherally via litre bags of maintenance fluid, such as 0.9% saline. We may use 20 - 60 mmol (is that the same as your milliequivalents?). The error that I made is that I put up a bag of 50ml 0.9% saline with 40mmol KCl in. The KCL made the total volume of fluid given up to 70ml, so 40 mmol potassium was given peripherally in just 70ml instead of a litre bag. This could have irritated the veins so was obviously potentially dangerous to the patient.

It is now 8 days after the event and the Unit where I work has decided to give all nursing staff an educational update of our responsibilities during drug administration, outlining the seriousness of our responsibilities.

Incidentally there have been a total of 7 drug errors in June alone, leaving 14 nursing staff unable to now give any drugs.There are approx 60 nursing staff on the Unit in total, many working part-time only.

I have still not been reassessed as being competent to give any drugs and the 'checker' at my drug error, an experienced nurse, who unfortunately was unaware that my patient had no central access, is also unable to check other nursing staff's drugs or administer any drugs at all, except under supervision by the Nurse in charge. We cannot even give enteral feeds, oral drugs or even prepare blood gas syringes by coating them with heparin prior to their use. All in all we are not much use at all at work. There may be just 5 staff on a shift and when the Sister or Charge Nurse is on their break, our patient is not able to have their drugs or feeds. We have to get other nurses to do our jobs. For one nurse I know on our Unit, it took them six weeks to reassess her. This is because we are just so short-staffed that it's difficult enough to cope with our workloads without other educational or teaching needs being attended to.

We have heard at work that one of the Nurses in Charge made the same mistake on the same patient but 'realised' after just a few mls were given, so stopped the IV. This occurred after my error, but as this nurse was one of the 'bosses' her error was deemed insufficient to be made an incident of, so of course she is not undergoing the usual punishment.

We know of other recent drug errors made by our Nurses in Charge which were covered up.

Morale on our Unit is exceptionally poor and we are losing on average 4 staff a month.

In reply to Nancy's wise and kind remarks regarding errors being seen as teaching opportunities.....I brought this up at our staff meeting last week. We were told by the Nurse Manager that talking about individual drug errors would be breaching staff confidences and would be unfair to staff concerned. I disagreed and asked that my own error be told to everyone to stop any further potassium errors being made.

Their argument is that we are responsible for the drugs we give and should know all the side effects, problems etc of all drugs we administer. The Unit has no responsibility for further education, even when the error is a recurring one, as being professional nurses we are personally accountable.

I understand their argument and take full responsibility for my own error but feel that they have a moral obligation to pass on educational information if they see knowledge deficits amongst their staff.

What do others think?

------------------

JillR · Jul 5, 2000

ICU Nurse,

Thank you for the response to my question, it makes sense to me now.

I do not believe that a nurse should be punished for a med error, unless these errors are made by the same nurse time after time. My reasoning in this is that if a nurse thinks themselves or others will be punished than I think the person may not report the error.

I also believe that if an error is made often by a number of nurses, than the facility should think about giving an inservice on this particular drug. I think that if there is trend here, then there must be a problem.

I have to admit that I have made not frug errors but I made an error when i signed off an order. I recieved a telelphone order to give Tagamet IV, gane it IV but didint write IV on the order and the ward clerk wrote the order for P.O. I was lucky in that the supervisor the next morning caught this and called me at home to clarify and there was no med error. There could have easily been an error and I would have been responsible.

However the hospital I work at does not punish for med errors, They will discuss this with you and probably there would be some kind of punishment if the problem continues to exist. I have never ecountered a problem like that.

I can't see how a facility can knowingly ignore the fact that there is aproblem with a certain med, consistantly with a number of different nurses, and ignore it and say that they have no resposibility in the matter. I would think that the facility would have some accountablilty for ensuring that its nurses are kept educated on such issues.

Do you have a policy and procedures manual, if so this potassium issue should be in it and if not then the facility should have one drawn up so that you all can refer to that when needed.

I would suggest to you and the other nurses on your unit to follow those procedures and let all new nurses ther know about it because it sounds to me like you will get no backing from the facility you work in if ther continues to be mistakes like this made.

I do believe that your supervisor that made the same mistake that you did is being held to a different degree of acountability here and that is not right.

Good luck ICU nurse. I can read the frustration in your writing and I will pray that things get better for you. TY JillR

Brit RN · Jul 13, 2000

If we make mistakes because of interuptions, and there are always so many interuptions, we must be assertive and ask the persons to come back later. It should be easy to say to a family member, I will come back when I have finished my med pass. As far as other peers go, they should know better. We all have made mistakes, and we need to reflect in order to improve our practice. After all it is in the best interests of the patients that we do.

Nurses who make med errors, need to be questioned as to why, one is understandable, thats how we learn. Repeated mistakes should not go un-noticed. In a perfect world no mistakes should ever be made, but we have to be realistic. If you continue to make mistakes, not that many people do, we should say, why is this happening and what can I do about it. It is part of nursing that we all reflect on our practice, we are professional people and should be proud of it.. If you are going to punish, what punishment are you going to give.

Nurseprotect · Jul 18, 2000

Originally posted by Anthony Marc:
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).]

JULY 16, 2000

Anthonymarc,

Are you really a Nurse? and if you are do you practice in direct bedside care, administering medications to real live patients? Your comments are those of someone who fails to realize their potential for error as a human being. Human factors are not an excuse, they are just an unfortunate fact of the way things are. You could be the nurse accidentally giving the undiluted IV Potassium push someday under the right (or wrong depending on how you look at it) circumstances. I am proposing that a moratorium be placed on all disciplinary action against health care professionals undergoing investigation for medication errors until a truly non-punitive medication error reporting system is in effect and systems are in place that enhance the clinician's ability to provide safe care. I don't know how things are at the bedside in Canada right now but here in the US they are pretty dangerous. I detect medication errors almost every shift that I work (at least 3 per week). You sound like a nurse working in Academia or Administration-far removed from reality of bedside care today. Anyone who thinks that they will absolutely never make a serious medication error no matter what happens is probably more dangerous than those of us realizing the scary potential for such an error to occur in our practice. I have not seen it yet, and I am sure such clinicians probably exist somewhere, but most nurses do not go to work with a careless and reckless attitude with the thought that they could care less if they harm someone. Excellent nurses make fatal medication errors. If you look at the research and practices of aviation safety you will learn that a certain amount of errors will occur regardless of the precautions implemented. This does not mean that we should abandon precautions but punishing and sanctioning nurses will not change the rate of medication errors. Why don't we review the competency of Nursing Administrators who place nurses into poorly staffed work environments where medication errors are more likely to occur? Have their license reviewed by the Board of Nursing/Licensing Authority.

The arrogance of your statements are of great concern. It sounds as if you have all of the answers to our medication error problem because you have apparently never made an error-Once again, do you work in direct care nursing?

While we are on the subject of errors, I would like to challenge any nurse to become intimately familiar with their Nurse Practice Act and Standards/Laws/Regulations to which they are held and work just ONE shift without violating at least one of those rules AS THEY ARE WRITTEN-the regulatory boards will hold you accountable to the letter no matter how unrealistic the expectation might be under the circumstances.

In my first year of nursing I was telling a group of nurses about the fact that the small town hospital Doctor and Nurses missed several serious injuries on a severe MVA Trauma patient and sent her home-a Physician overheard my remarks and replied "haven't you ever missed something before?" That moment was a big learning experience for me. Let me know when you find the perfect clinician.

My first thoughts on the Dana Farber Nurses and the Chemotherapy overdose (lots of national press on this several years ago), and the Colorado nurses who gave Penicillin for IM injection Intravenously to a neonate (both resulted in patient death) was "what in the Hell were these nurses thinking?!!!" After reading the facts of these cases recently it was very clear that they were thinking and it was system issues that led to the patient deaths. This subject has struck a raw nerve with me, especially when I see another nurse proposing an attack against my colleagues at the bedside. Most of us want to provide safe care. We don't deserve to be shamed and humiliated. Accountability should be shared with all persons in charge of the systems leading to the error if we feel that we must make someone answer to the mistake.

I have not made any serious or fatal errors but I am acutely aware of the fact that the difference between a "minor" error not leading to harm and a fatal error could just be luck-and that is scary.

I am always willing to substantiate and clarify ANYTHING that I say or write-Any questions?

------------------

Steven S. Lee, RN

Chief Voluntary Officer

Nurseprotect

[email protected]

PPL, BSN, RN · Jul 18, 2000

What say you, Anthony Marc?

egmillard · Jul 18, 2000

People make mistakes, Doctors make mistakes, even nurses make mistakes. We must examine the reasons behind those mistakes, in order to control them, however we do not live in a perfect world, and we cannot control everything.

Nurseprotect · Jul 30, 2000

Originally posted by ICUNurse:

Originally posted by JillR:
ICUnurse,

I don't quite understand the problem here. We administer potassium all the time throught periphereal IV's. We use liter bags though. Is it the concentration of the potassium thats the problem? Sorry but I just want to get this straight. I am assuming that the concentration of the potassium is irritating to the veins? Could you please enlighten me. Thanks. JillR
In the ICU I work in, we also give potassium peripherally via litre bags of maintenance fluid, such as 0.9% saline. We may use 20 - 60 mmol (is that the same as your milliequivalents?). The error that I made is that I put up a bag of 50ml 0.9% saline with 40mmol KCl in. The KCL made the total volume of fluid given up to 70ml, so 40 mmol potassium was given peripherally in just 70ml instead of a litre bag. This could have irritated the veins so was obviously potentially dangerous to the patient.

It is now 8 days after the event and the Unit where I work has decided to give all nursing staff an educational update of our responsibilities during drug administration, outlining the seriousness of our responsibilities.

Incidentally there have been a total of 7 drug errors in June alone, leaving 14 nursing staff unable to now give any drugs.There are approx 60 nursing staff on the Unit in total, many working part-time only.

I have still not been reassessed as being competent to give any drugs and the 'checker' at my drug error, an experienced nurse, who unfortunately was unaware that my patient had no central access, is also unable to check other nursing staff's drugs or administer any drugs at all, except under supervision by the Nurse in charge. We cannot even give enteral feeds, oral drugs or even prepare blood gas syringes by coating them with heparin prior to their use. All in all we are not much use at all at work. There may be just 5 staff on a shift and when the Sister or Charge Nurse is on their break, our patient is not able to have their drugs or feeds. We have to get other nurses to do our jobs. For one nurse I know on our Unit, it took them six weeks to reassess her. This is because we are just so short-staffed that it's difficult enough to cope with our workloads without other educational or teaching needs being attended to.

We have heard at work that one of the Nurses in Charge made the same mistake on the same patient but 'realised' after just a few mls were given, so stopped the IV. This occurred after my error, but as this nurse was one of the 'bosses' her error was deemed insufficient to be made an incident of, so of course she is not undergoing the usual punishment.

We know of other recent drug errors made by our Nurses in Charge which were covered up.

Morale on our Unit is exceptionally poor and we are losing on average 4 staff a month.

In reply to Nancy's wise and kind remarks regarding errors being seen as teaching opportunities.....I brought this up at our staff meeting last week. We were told by the Nurse Manager that talking about individual drug errors would be breaching staff confidences and would be unfair to staff concerned. I disagreed and asked that my own error be told to everyone to stop any further potassium errors being made.

Their argument is that we are responsible for the drugs we give and should know all the side effects, problems etc of all drugs we administer. The Unit has no responsibility for further education, even when the error is a recurring one, as being professional nurses we are personally accountable.

I understand their argument and take full responsibility for my own error but feel that they have a moral obligation to pass on educational information if they see knowledge deficits amongst their staff.

What do others think?

I think you should get out of that hellhole of an ICU you are working in. Your administration is dangerous and incompetent. I would appreciate it if you forward this message to them (I am assuming this would be if and when you leave your current position there). At the very least, obtain a copy of a book titled "Medication Errors Causes, Prevention, and Risk Management" by Edited by Michael R. Cohen and have the administrative staff read it AND USE THE SUGGESTIONS IN IT. Refer them to the Institute for Safe Medication Practices and the United States Pharmacopeia web sites for more information on medication errors. To quote directly from the book cited above "Although the nearest error leading to an accident is usually a human one, the causes of that error are often well beyond the individual's control. SYSTEMS THAT RELY ON PERFECT PERFORMANCE BY INDIVIDUALS TO PREVENT ERRORS ARE DOOMED TO FAIL, FOR THE SIMPLE REASON THAT ALL HUMANS ERR, AND FREQUENTLY. If doctors, nurses, pharmacists, and administrators are to succeed in reducing errors in health care, they must change the way they think about errors and why they occur." "Delivery of a single dose of a medication is the end result of a complicated process involving 10 to 15 steps, each of which offers an opportunity for error."

I am sorry that you have been treated poorly and shamed by ignorant colleagues and administrators but you must realize that nurses are an easy target for blame in organizations throughout the world-WE ARE JUST BECOMING LESS WILLING TO PUT UP WITH IT ANY MORE. It sounds like it is just as bad to work at the bedside in the UK as it is in the United States. Feel free to contact me at my e-mail address below. Nurseprotect exists to support nurses in situations such as the one you are in now. You do not deserve this. I also want to mention that it is almost certain that considerably more than 6 nurses in your ICU have made medication errors. Once again, it sounds like you are dealing with one of the most incompetent and dangerous hospital administrations in existence.

Take care and try to find a "safer" job, if that exists in health care today-like maybe Chief Executive Officer or something : )

------------------

Steven S. Lee, RN

Chief Voluntary Officer

Nurseprotect

[email protected]

GLORIAmunchkin72 · Nov 28, 2004

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 .

How can you punish a nurse who is trying to do 10 different things? The staff should brainstorm and think how everyone can make things better and safer. That is if the nurse in question is basically a responsible person.

cannoli · Nov 28, 2004

In the ICU I work in, we also give potassium peripherally via litre bags of maintenance fluid, such as 0.9% saline. We may use 20 - 60 mmol (is that the same as your milliequivalents?). The error that I made is that I put up a bag of 50ml 0.9% saline with 40mmol KCl in. The KCL made the total volume of fluid given up to 70ml, so 40 mmol potassium was given peripherally in just 70ml instead of a litre bag. This could have irritated the veins so was obviously potentially dangerous to the patient.
It is now 8 days after the event and the Unit where I work has decided to give all nursing staff an educational update of our responsibilities during drug administration, outlining the seriousness of our responsibilities.
Incidentally there have been a total of 7 drug errors in June alone, leaving 14 nursing staff unable to now give any drugs.There are approx 60 nursing staff on the Unit in total, many working part-time only.
I have still not been reassessed as being competent to give any drugs and the 'checker' at my drug error, an experienced nurse, who unfortunately was unaware that my patient had no central access, is also unable to check other nursing staff's drugs or administer any drugs at all, except under supervision by the Nurse in charge. We cannot even give enteral feeds, oral drugs or even prepare blood gas syringes by coating them with heparin prior to their use. All in all we are not much use at all at work. There may be just 5 staff on a shift and when the Sister or Charge Nurse is on their break, our patient is not able to have their drugs or feeds. We have to get other nurses to do our jobs. For one nurse I know on our Unit, it took them six weeks to reassess her. This is because we are just so short-staffed that it's difficult enough to cope with our workloads without other educational or teaching needs being attended to.
We have heard at work that one of the Nurses in Charge made the same mistake on the same patient but 'realised' after just a few mls were given, so stopped the IV. This occurred after my error, but as this nurse was one of the 'bosses' her error was deemed insufficient to be made an incident of, so of course she is not undergoing the usual punishment.
We know of other recent drug errors made by our Nurses in Charge which were covered up.
Morale on our Unit is exceptionally poor and we are losing on average 4 staff a month.
In reply to Nancy's wise and kind remarks regarding errors being seen as teaching opportunities.....I brought this up at our staff meeting last week. We were told by the Nurse Manager that talking about individual drug errors would be breaching staff confidences and would be unfair to staff concerned. I disagreed and asked that my own error be told to everyone to stop any further potassium errors being made.
Their argument is that we are responsible for the drugs we give and should know all the side effects, problems etc of all drugs we administer. The Unit has no responsibility for further education, even when the error is a recurring one, as being professional nurses we are personally accountable.
I understand their argument and take full responsibility for my own error but feel that they have a moral obligation to pass on educational information if they see knowledge deficits amongst their staff.
What do others think?
------------------

I think it's nuts that none of you can pass meds!

I agree with you, the entire staff should be reminded of the potassium policy, what's the big deal with mentioning it during your staff meeting.

As far as the charge nurses mistakes being covered up, that sounds like a good reason to look for another job. (Then they can give all the meds, they'll be the only ones there.)

Good luck.

cannoli · Nov 28, 2004

I just noticed, this thread is 4 1/2 years old! How did this get up here?

Pattiecake · Nov 28, 2004

It may be 41/2 years old, but it still seems to be an unresolved topic.

Pat

Bill Levinson · Dec 3, 2004

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.

I posted material on the application of the ISO 9000 quality system to health care elsewhere in this forum. Punishing the nurses for drug errors is almost prima facie evidence of managerial incompetence on the part of the hospital, unless the nurse was actually egregiously negligent. The system in which the nurse works is to blame most of the time (the rule of thumb is 85%) so if anyone should be disciplined, it is the hospital administrators!

See http://www.pennyslvaniahealth.org/iso9000.html for more on this. There are many places in the process (doctor, pharmacist, nurse) in which a medication error can occur. A good quality system will prevent errors from happening.