Non-punitive med error policy

DusktilDawn · Aug 16, 2005

i agree that alot of med errors don't get reported for fear of reprisals. i agree that there also needs to be focus on the system also. there can be numerous factors in the working environment that can cause medication errors that never seem to be addressed:

1. interruptions. how many times are you interrupted when dispensing meds. there are all kinds of circumstances when your interrupted.

2. late administration, wrong time. a real problem at times where i work. despite 3-4 calls to pharmacy on orders sent down and receiving medication 8 hours after orders were sent. also you can't always provide total patient care and be on time with your medications. i've had mars sent with meds scheduled for 2100 for example and the patient had been admitted at 0100 on the unit and the orders were sent at 0105.

3. stat medications not readily available. i've sent stat orders for a medication and not received it until 4 hours later, despite calling pharmacy and telling them i just sent a stat order.

4. wrong dosages. i've received medications that were the wrong dosage. if it's a new medication i always check the orders. i've had mars printed and sent that were missing medications that were ordered, and no these were not new orders, these were admitting orders. although as a nurse you are supposed to check your orders, there are times i can't even thoroughly go through the chart until 4-6 hours into my shift. i've received ivpbs with the wrong infusion printed on the label, if i'm not familiar with a medication i always double check it, sometime asking a co-worker to double check with me.

5. wrong route. real problem with administration via ng. some of the medications ordered should not be crushed. i've had many patients become angry because "the other nurse" crushed the meds and pushed them through the ng and i wanted to them to take them po (not contraindicated). i had one new employee who crushed all the meds and mixed them together and then flushed them down the ng, thankfully she is no longer working there. i've had medications ordered im that the previous nurse gave iv (yes, med could have been given iv if ordered that way), i then have to call to change the order to iv because patient refuses im.

6. inadequate instructions/insert provided with medication. this is so true with medications that we normally do not administer. i had a patient who required immunization shots and i was not provided any information concerning what i was administering. there are some medications where certain muscles cannot be used for im. some immunizations you can't administer on the same day as another, had to call pharmacy for instruction.

7. policy and procedures on-line. try and find it, good luck. :angryfire it's taken me 20-45 minutes to find something. wasting time is a huge pet peeve, especially when it concerns info i feel i should be able to have easy access to. :angryfire

8. iv compatabilities and protocols. no manual on unit. have to call pharmacy, like they're not busy. alot of the staff don't know what the protocol is for administering hydralazine ivpb and it is not an uncommon order for our unit. i previously worked at a place that had an iv formulary on the unit, the great thing was that if i was unfamiliar with a iv medication, i could photocopy that particular med administration and compatibility and place it in the mar. our pyxis had a medication list to look up meds, few know that its there.

9. iv pumps. we have triple pumps where you have to be very careful not to mix up the lines. pt had a dl picc and tpn & lipids infusing, the lipids were infusing in her peripheral site, instead of her ivfs with pca. i've taken to labeling iv tubing in these situations. also you have to stop the infusion on these pumps and to change the rate.

i do feel a big problem in our facility is that there is inadequate orientation regarding utilization of policy & procedures on-line, tpn & lipid administration, ng administration, use of equipment. few of the people i work with (some have been there years longer than me) have no idea how to utilize the on-line reporting for incidents. information needs to be more easily accessed where i work. the things i learned after i was done orientation. :uhoh3: last place i worked at had a committee comprised of both pharmacy and nurses for the purpose of decreasing med errors. reported errors were reviewed with the goal of improving the system.

good topic sbic56.

sbic56, BSN, RN · Aug 16, 2005

DusltilDawn

Thanks for posting! You bring up a ton of excellent examples of systems errors that inevitably lead to med errors. I think it is the rare nurse who is merely so incompetent that they cannot pass meds safely and that most often, there is a problem that can be rectified. I love the idea of your online reporting for incidents...how does that work? I've not seen it here.

ZASHAGALKA, RN · Aug 16, 2005

i agree w/ tweety, nevermind.

~faith,

Timothy.

DusktilDawn · Aug 16, 2005

DusltilDawn
Thanks for posting! You bring up a ton of excellent examples of systems errors that inevitably lead to med errors. I think it is the rare nurse who is merely so incompetent that they cannot pass meds safely and that most often, there is a problem that can be rectified. I love the idea of your online reporting for incidents...how does that work? I've not seen it here.

Hi Sbic56,

Our facility has its own web site where we can connect to our on-line incident report. This form can be used to report med errors, accidents involving patients or staff, transference of care issues, safety concerns, etc. This form also can take about 20 minutes to fill out which is another downside to it. It is automatically forwarded to risk management and is reviewed, also a copy will be sent to the UM. The biggest problem with our on-line reporting is that many of the staff do not know how to access it, I had someone call me at home because they needed to fill out an incident involving a needle stick injury, my co-worker did not know the passwords to access the form. The problem I feel with our on-line reporting is lack of orientation to it to new employees, I had to figure out how to access this system on my own, and the design of the form, there are many areas to fill out on that I don't think are necessary, alot of people don't want to be bothered to fill them out because they are time consuming and confusing. A co-worker remarked that when they went to this on-line format that there was probably a big decrease in reporting safety events, I wouldn't be if there was a 75% reduction in incident reports since they went to this system. After if staff don't know how to use it, how can they report it.There is a section on the form where you can give your suggestions on how to prevent future occurrences of an incident, which I think is important. I like the idea of on-line reporting, however I do feel that there needs to be improvements with the actual format our facility uses, orientating staff and new employees on how to use this form, and providing feedback on incidents filed to encourage staff to utilize this tool of advocacy. Another factor that discourages alot of nurses from filing incident reports is the idea that it changes nothing. I have expressed all of these concerns to my UM.

Here's a couple more safety factors I thought of:

1. Medications in similiar packaging. There have been numerous examples in the news on this. For instance, last facility I worked at had demerol 25mg and demerol 50mg in glass vials of the same size & colour except one had an orange band on it and the other had a red band. Now orange and red are too close in the colour spectrum in my opinion. We have pyxis where I'm at and most of our IM/IV narcotics all come in similiar vials, I can see a mistake happening if you push a wrong selection.

2. Labels that are hard to read. Small vials with miniscule print, very easy to misread. I can't tell how many times a co-worker has asked me to read a label for them.

I agree that it is the rare nurse who is grossly incompetent. I also noticed that when measures are implemented or discussed on how to decrease med errors there is very little input from the nursing staff if any, and nobody seems to look at the work environment at all.

One of the moderators NRSKaren posted a site about medication errors:

http://www.nursingcenter.com/library/JournalArticle.asp?Article-ID=574053

I hope there are more replies to this thread.

Tweety, BSN, RN · Aug 16, 2005

Sorry. nevermind. :)

DusktilDawn · Aug 16, 2005

I think reporting incidents that could cause potential errors is another tool for nurses to provide a safer environment for our patients.

sbic56, BSN, RN · Aug 16, 2005

I think reporting incidents that could cause potential errors is another tool for nurses to provide a safer environment for our patients.

Yes, potential errors will eventually become actual errors! I definitely like this proactive approach. It takes alot more effort from managment to try and avoid errors in the first place rather than the traditional and ineffective disciplinary measures after the fact and since reducing errors is the goal, I'll be glad to see this become the norm. I know I'm going to be putting this "potential error" reporting system into effect where I work. I, too, hope to see some more people jump in here. This is important stuff!

sbic56, BSN, RN · Aug 16, 2005

Tweety, ZASH

Darn, sorry to see you deleted your comments. All opinions are valid here! Wish I had a chance to see your thoughts on this.

Blackcat99 · Aug 16, 2005

I think some nurses don't report other nurse's med errors because they don't have the time to do so especially if one is working LTC. If you are the nurse who discovers a medication error you are "punished" for discovering it since you are then required to fill out all the paperwork, call the doctor etc. etc. etc.

sbic56, BSN, RN · Aug 16, 2005

I think some nurses don't report other nurse's med errors because they don't have the time to do so especially if one is working LTC. If you are the nurse who discovers a medication error you are "punished" for discovering it since you are then required to fill out all the paperwork, call the doctor etc. etc. etc.

I think I understand what you are saying. If there is no review system in place and no research completed as to why the med errors occurs, the the system is useless. My thinking is that the extra effort that is taken to recognize/report the medication error, needs to be followed up in such a way that future errors of that type are avoided. Often the system is at fault, but cannot be corrected unless the problem is exposed. Learning by mistakes, whether your own or someone elses is the way to avoid future mistakes, thus reduce errors and the need to make out more time consuming reports. Safer care for the pateint is the ultimate desired result, right?

pickledpepperRN · Aug 16, 2005

Link to book To Err is Human - http://www.nap.edu/openbook/0309068371/html/

The JCAHO on errors. Interesting testimony:

http://www.jcaho.org/news+room/on+capitol+hill/oleary_test.htm

* Protecting and supporting - rather than punishing - caregivers who make errors. When caregivers feel safe, patients are more likely to be safe because such strategies create opportunities to truly learn from identified errors.

* Incenting and promoting counter-cultures of safety. This is a non-delegable responsibility of organizations leaders; those having the courage to rise to this challenge should be rewarded.

* Expanding the applied knowledge base and training of future generations of clinicians to include systems thinking and analysis and training - tried and true approaches used in other high-risk industries to improve safety.

Dr. O' Leary,... "Most health care errors and even serious adverse events are not made known to organization leaders. This is principally because health care professionals involved in such occurrences are deeply shamed and, at the same time deeply fearful of the humiliation and punishment that all too often has been the knee-jerk response to human error by organization leaders as well as by professional licensure boards and state and federal quality oversight bodies.

In truth, if responsibilities are to be assigned, they have lain, and continue to lie, with organization leaders in assuring that safety is prospectively (and today retrospectively) built into all vulnerable organization systems and processes that have the potential to impact patient care. Humans, including health care professionals, will always make errors. The goal, we now understand, is to prevent those errors from reaching or affecting the patient. And the continuing challenge for all of us is to leverage and incent health care organizations and health care professionals to invest in these preventive efforts."...