Top 10 Reasons We Get Fired!- Medication Errors - page 2

Number 5 in my series of Articles about the top ten things to get fired, discusses medication errors. Making mistakes in health care tends to be frowned upon more than any other career, the... Read More

  1. by   Overland1
    Quote from mind_body_soul RN
    We were taught TRAMPED (same as above with the addition of Expiration date and Documentation)
    Cool! Looks like a great way to remember the "extra" (but very important) stuff. When I was in school (Dark Ages), the instructors were very proper; I still recall one who became very upset when a student used the term "butt" (referring to buttock). I will concede that such probably does not sound professional. While we were discussing it among ourselves, I explained that "butt" also means "shoulder", as in going to the butcher shop and buying a Boston Butt... definitely not the part taken from the south end of a north-facing pig.
  2. by   stitcher75
    My response is a bit different than those above...mainly because I'm not a nurse (yet.) The company I work for is working hard to improve processes through the principles of Lean and Six Sigma. A Lean process is one with no waste (i.e. every step in the process provides value to the customer/patient or is required by a regulatory agency.) A Six Sigma process is one for which there are no more than 3 errors/million opportunities to make an error.

    As someone who has extensive experience as a patient and who is being trained in Lean Six Sigma, I know that hospitals have made great strides in reducing medication error rates, but that Lean Six Sigma principles could be used to reduce or eliminate "wasted steps" so as to minimize the opportunities for error.

    Also, from my vast experiece as a patient, I firmly believe that the single most important thing a nurse can do when (s)he administers medications is to tell the patient (or the medical POA) the name (trade and generic) of the drug, why it was prescribed, the prescribed dose, and the prescribing physician...EVERY TIME. It takes longer; it feels tedious and redundant, but it helps the patient feel like (s)he is respected and is part of the process AND it works as a triple check that the right med is going to the right patient in the right amount at the right time.

    Finally, before they go home with a prescription, patients should be taught to ask all of those questions and what are the potential side effects, are there any food-drug or drug-drug interactions (including alcohol or tobacco), is it approved for use in pregnant our breast feeding women. Give them the link to the Pill Identification Wizard from Drugs.com and tell them to check it and call the pharmacist ANY TIME something doesn't look right.

    This subject is near and dear to my heart. In the past 30+ years (beginning as a pre-teen), I've had my share of near misses from doctors, nurses and pharmacists. In some cases, the drug had gone generic; in some it was a new generic manufacturer; but in more than a few, I'd been prescibed or given the wrong medicine. But because I knew what I took, why I took it, and what it looked like, I was never actually administered the wrong medicine.

    Your single greatest ally in preventing medication errors can and should be your patient.

    (my 2 cents)
  3. by   anon456
    Quote from stitcher75
    My response is a bit different than those above...mainly because I'm not a nurse (yet.) The company I work for is working hard to improve processes through the principles of Lean and Six Sigma. A Lean process is one with no waste (i.e. every step in the process provides value to the customer/patient or is required by a regulatory agency.) A Six Sigma process is one for which there are no more than 3 errors/million opportunities to make an error.

    As someone who has extensive experience as a patient and who is being trained in Lean Six Sigma, I know that hospitals have made great strides in reducing medication error rates, but that Lean Six Sigma principles could be used to reduce or eliminate "wasted steps" so as to minimize the opportunities for error.

    Also, from my vast experiece as a patient, I firmly believe that the single most important thing a nurse can do when (s)he administers medications is to tell the patient (or the medical POA) the name (trade and generic) of the drug, why it was prescribed, the prescribed dose, and the prescribing physician...EVERY TIME. It takes longer; it feels tedious and redundant, but it helps the patient feel like (s)he is respected and is part of the process AND it works as a triple check that the right med is going to the right patient in the right amount at the right time.

    Finally, before they go home with a prescription, patients should be taught to ask all of those questions and what are the potential side effects, are there any food-drug or drug-drug interactions (including alcohol or tobacco), is it approved for use in pregnant our breast feeding women. Give them the link to the Pill Identification Wizard from Drugs.com and tell them to check it and call the pharmacist ANY TIME something doesn't look right.

    This subject is near and dear to my heart. In the past 30+ years (beginning as a pre-teen), I've had my share of near misses from doctors, nurses and pharmacists. In some cases, the drug had gone generic; in some it was a new generic manufacturer; but in more than a few, I'd been prescibed or given the wrong medicine. But because I knew what I took, why I took it, and what it looked like, I was never actually administered the wrong medicine.

    Your single greatest ally in preventing medication errors can and should be your patient.

    (my 2 cents)

    I so agree with this!! There were a few times when I would go over the nighttime meds with the parents of my patients and they would have questions, be unaware that a certain med was prescribed, or there were two different doses of the same med (one for morning one for night).

    I have had a couple of near-misses that were saved because I took the TIME to review the R's. We have oral/gt meds already drawn up and delivered by pharmacy. They go in bins with the patient's room number in the med room. Sometimes a patient is discharged and another one is admitted, but the old patient's meds are still in the med drawer. I once had the right med, dose, time, etc. but at the bedside I checked the patient's armband and it was the previous patient! Huge coincidence that it was the same med and dose of previous patient, but a common med that's used on our unit.

    Once I pulled out the wrong dose (because of the AM and PM being different) and sat down at the computer before going in the room with the 10 or so bedtime meds, and I caught that one.

    It's so scary when you have chronic patients with so many bedtime meds to give and other meds through the night for their acute condition. I would rather be late with meds than to make a med error.
  4. by   xoemmylouox
    Quote from anon456

    I so agree with this!! There were a few times when I would go over the nighttime meds with the parents of my patients and they would have questions, be unaware that a certain med was prescribed, or there were two different doses of the same med (one for morning one for night).

    I have had a couple of near-misses that were saved because I took the TIME to review the R's. We have oral/gt meds already drawn up and delivered by pharmacy. They go in bins with the patient's room number in the med room. Sometimes a patient is discharged and another one is admitted, but the old patient's meds are still in the med drawer. I once had the right med, dose, time, etc. but at the bedside I checked the patient's armband and it was the previous patient! Huge coincidence that it was the same med and dose of previous patient, but a common med that's used on our unit.

    Once I pulled out the wrong dose (because of the AM and PM being different) and sat down at the computer before going in the room with the 10 or so bedtime meds, and I caught that one.

    It's so scary when you have chronic patients with so many bedtime meds to give and other meds through the night for their acute condition. I would rather be late with meds than to make a med error.
    Being late with a med IS a med error. I have seen many employers want you to self report, but they then punished those who reported harshly. Med errors are dangerous and in nearly all cases preventable. It's just human error from constant interruptions, patient over load, lack of experience, fatigue, etc.
  5. by   Ruby Vee
    Quote from xoemmylouox
    Being late with a med IS a med error. I have seen many employers want you to self report, but they then punished those who reported harshly. Med errors are dangerous and in nearly all cases preventable. It's just human error from constant interruptions, patient over load, lack of experience, fatigue, etc.
    Whether or not being late with a med IS a med error depends upon how late and upon how frequently a med is given. Giving a daily med two hours late is a whole lot different than when the med is due every four hours.
  6. by   anon456
    Quote from xoemmylouox
    Being late with a med IS a med error. I have seen many employers want you to self report, but they then punished those who reported harshly. Med errors are dangerous and in nearly all cases preventable. It's just human error from constant interruptions, patient over load, lack of experience, fatigue, etc.
    Something I tell those that I precept-- it's way better to be late than to make a mistake. I bust my butt trying to get the meds to the kids on time, but being human, we can only do so much when so much is demanded of us. The antibiotics and other time sensitive meds are given on time.

    My unit is full of kids who get literally 10-14 medications at bedtime, some of which have to be crushed for g-tube. Since many of those are BID and not time-sensitive it's okay to be late if it means being safe to take the time to check the right dose for that weight, and know exactly what you are giving. I am not going to give a med to someone if I don't know what it is-- and if I don't know what it is, how do I know the dose is safe? Technically yes, being late is a med error, but as long as I'm not *that* late-- and I document exactly when I gave it, I'd rather explain why I was late late giving a med than try to explain why I gave the wrong dose of seizure med to the wrong patient because I was rushing to get the meds in on time.

    Also we don't have CNA's on the unit some nights, and we have to do all our vitals, diaper changes (even on big people), set up tube-feedings for the night, appease the family members of the patients, and comfort kids whose families have left them alone. Not to mention we are a trach/vent unit so safety checks, suctioning, vent alarm responses. It's all about prioritizing. And when I have to prioritize, safety comes #1 in all cases. While all of the "R's are important, some of the R's more important than others in the real world.
    Last edit by anon456 on Jan 27, '14
  7. by   lumbarpain
    giving meds can be tedious but nothing can be compared to getting into a great safe routine to give meds.....Tramped is an excellent way to remember the right way to dispense meds to patients.....we have so much to remember, so much going on at once, so much multi tasking...its good to get a good routine.....however.....checking an order inbetween meds is very time consuming....you cannot check every order to see if its changed.....good communication between nurses/staff is so essential also.....one time I got in trouble...I gave a dose of Coumadin when the lab report had just come in and things crisscrossed....the day nurse didn't tell me that the lab report did not come in on her time....but it slid in After 3pm....so it sat there for a time indicating that this patient needed his medicine decreased....but it was never relayed to me that this report came in.....so we must be alert to check faxes and ask about any reports that came in when we come onto the shift cause other staff may just forget...and then you are the scapegoat.
  8. by   subee
    Quote from Ruby Vee
    I think management recognized that everyone makes mistakes. And these nurses handled the mistakes the right way -- the moment they realized they'd made a mistake, they self reported and then set about attempting to mitigate the damage to a patient. They didn't try to hide the mistake, and they were smart enough to realize that they'd MADE a mistake. These weren't nurses who made mistake after mistake, never learning from them. THOSE are the dangerous nurses.

    And the "wonder what they had to do to keep their jobs . . . . hmmmm." was just nasty.
    A nurse gave a patient 10 Digoxin tablets....this is waaaay beyond an error that could happen to anyone. This is an egregiously stupid error and I would never reward that stupidity with a promotion to management. P.S. You have a dirty mind. I wasn't thinking dirty - just imagining the person as becoming a tool.
    Last edit by subee on Jan 29, '14 : Reason: misspelling
  9. by   Ruby Vee
    Quote from subee
    A nurse gave a patient 10 Digoxin tablets....this is waaaay beyond an error that could happen to anyone. This is an egregiously stupid error and I would never reward that stupidity with a promotion to management. P.S. You have a dirty mind. I wasn't thinking dirty - just imagining the person as becoming a tool.
    Worse than that, she injected 10 vials of digoxin. BUT she paid. She was devastated. The hospital moved her to a less acute patient care area where she worked for several years, becoming a preceptor and charge nurse. She headed a hospital wide committee and wrote articles for publication. After several years, she moved back into ICU and excelled as a nurse, obviously having learned her lesson about how many unit doses makes a bad idea. And after a few years in ICU as an excellent nurse, she was promoted to management. She wasn't a stupid woman, she just made one horrific mistake on her very first day off orientation. I had a lot of respect for the way she handled that medication error and with the way she handled people who were determined not to let her forget it. She was a class act all the way.
  10. by   subee
    Ruby: You're right. She does sound like a class act. It brought back awful, smelly memories of a student (over 30 years ago) who boiled a patients urine to make it a "sterile" specimen. I remember thinking that I could never, ever actually hire this person if she came looking for a job. Thanks for the long view.
  11. by   Deena Dooley
    Good article. However, dismissal of RNs in regards to self reporting or non-self reporting medical errors directly impacts retention and/or recruitment. A plan should be developed to better address medical errors within health care.
  12. by   hope3456
    Quote from DoGoodThenGo
    Has been almost three years and is still my *favourite* (if that is the proper word) example of a medication error and the actions that followed that took the gold for running, standing and jumping. Nurse's suicide highlights twin tragedies of errors - Health - Health care | NBC News We shall never know the full story behind the situation surrounding nurse Kimberly Hiatt. But that a well seasoned nurse with nearly a quarter century of experience under her belt could been treated so badly by her hospital, and apparently the state BON and or everyone else in the profession in that area speaks volumes. Even worse that this same experienced nurse chose to end her life rather than deal with what she saw as the real prospect of being never able to practice again also speaks volumes.
    I think of her often. She self reported - otherwise probably no one would have known.
  13. by   Ruby Vee
    Quote from subee
    Ruby: You're right. She does sound like a class act. It brought back awful, smelly memories of a student (over 30 years ago) who boiled a patients urine to make it a "sterile" specimen. I remember thinking that I could never, ever actually hire this person if she came looking for a job. Thanks for the long view.
    Boiled a patient's urine? It boggles the mind!

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