Non-punitive med error policy

DusktilDawn · Aug 16, 2005

Excellent links Spacenurse!!

caroladybelle, BSN, RN · Aug 17, 2005

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.

When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.

While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

DusktilDawn · Aug 17, 2005

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.
When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.
While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

I agree. When it is clear that a person is persistently shoddy in their care there needs to be a process in place to prevent these people from causing continued harm to their patients. Anyone go over your boss' head concerning this person?

sbic56, BSN, RN · Aug 17, 2005

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.
When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.
While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

That's the dilemma; the rare bird like her. There is the safety issue when the nurse is just plain dangerous in her actions. So, what I am saying is, handle the med errors in a non-punitive way, but let staff know that there are certainly repercussion for continued shody, dangerous practices and let the overall evaluation of the employees work be the guide to whether or not they are competent to care for patients.

I know there has to be a line, but I so hate to have a "ticker" going, so to speak, where there is that atmosphere of impending doom where the nurse thinks, "oh, no....one more med error and I'm a gonner" as, 1)there is going to be another med error and that in itself shouldn't determine a nurses competency 2) she may fear reprisal and not report it in the first place.

I agree there has to be some kind of process in place to maintain the safety of the clients, but the staff need to feel secure in knowing that making a few med errors is not going to mean they are being closely watched until the the next one comes along. That is atmosphere is horrible to work in and is ineffective in reducing medication errors.

mydesygn · Aug 19, 2005

While I use to be a big fan of the nonpunitive approach to med errors, there have been times when it is deterimental to the patient.
When one of the boss's favorites made continual and repeated narcotic errors as well as errors of omission regarding PRN BP meds, nothing was done. Then the nurse in question nearly killed someone by mixing up antibiotics and a rather dire chemo error, well, she continues to wreak havoc but at another facility now.
While we need to be nonpunitive with the ocasional and less than threatening error, there does need to be a process in place to prevent those that are shoddy in their care.

In Texas, the Board of Nursing promotes the practice of internal peer review. For instance, a nurse who has made 3 minor errors or major errors is taken to peer review where staff nurses review the errors and the nurse's practice and make recommendations regarding reporting to the Board, more education etc.. The primary reason for this is to prevent the BON from becoming bogged down in investigating minor errors. If done correctly, situtions like the one you described would have been prevented since the nurse would have gone before peer review and subsequently reported if necessary. However, any system is oopen for abuse, sometimes "sham" peer reviews can result as a way of punishing nurses by bringing them to peer review for any minor error.

In one of the facilites I worked at peer review was used in such a manner. There was a "no tolerence" attitude. I know of several instances that nurses did not report errors in their own practice or someone elses because they did not want them to get in trouble. These were typically minor errors but unfortunately they continued because the root cause was never addressed and the errors remained unreported. It was just a matter of time before a major incident occured.

DusktilDawn · Aug 19, 2005

In Texas, the Board of Nursing promotes the practice of internal peer review. For instance, a nurse who has made 3 minor errors or major errors is taken to peer review where staff nurses review the errors and the nurse's practice and make recommendations regarding reporting to the Board, more education etc.. The primary reason for this is to prevent the BON from becoming bogged down in investigating minor errors. If done correctly, situtions like the one you described would have been prevented since the nurse would have gone before peer review and subsequently reported if necessary. However, any system is oopen for abuse, sometimes "sham" peer reviews can result as a way of punishing nurses by bringing them to peer review for any minor error.
In one of the facilites I worked at peer review was used in such a manner. There was a "no tolerence" attitude. I know of several instances that nurses did not report errors in their own practice or someone elses because they did not want them to get in trouble. These were typically minor errors but unfortunately they continued because the root cause was never addressed and the errors remained unreported. It was just a matter of time before a major incident occured.

There needs to be a medium between working to improve medication safety for the patient while avoiding the "witch hunt" mentality. I worked with one seasoned nurse whose FIRST medication error was a WHOPPER that involved a heparin gtt. This was a concscientious, caring, hard working individual, but alas she is human. Fortunately there was no harm to the patient, but the doctor was demanding her head, referring to her as incompetent. Funny thing, when I started working at this facility, 2 nurses had to verify if a heparin gtt was set properly. When this incident occurred, that policy had been changed so that you did not need another nurse to verify the gtt rate. Funny though, policy changed when staff was decreased prior to this incident. I think because no harm befell the patient is the only reason this person was not crucified, and is still practicing.

Home Health Columnist / Guide · Aug 19, 2005

the institute for safe medication practices has much info on this topic.

we offer a wide variety of free educational materials and services on our website (www.ismp.org):
special medication hazard alerts
searchable information on a wide variety of medication safety topics
answers to frequently asked questions about medication safety
fda patient safety videos
three pathways for medication safety tools:
a model strategic plan for medication safety , risk assessment tools and
questions for clinicians
readiness assessment for bedside bar coding
white papers on bar-coding technology and electronic prescribing
a monitored message board to share questions, answers, and ideas.

also, free nursing newsletter that is top notch! i disseminate to all the staff at my homecare agency.

sbic56, BSN, RN · Aug 19, 2005

the institute for safe medication practices has much info on this topic.
also, free nursing newsletter that is top notch! i disseminate to all the staff at my homecare agency.

fantasic site, karen! i like the message board idea. what better way to avoid an error than to learn by others mistakes or near misses? perfect.

JKDON · Feb 27, 2006

We do have a progressive discipline program for med errors but i developed a new tool that helps the person filling out the form, identify what the possible causes were. (overtime, new to assignment, med packaged differently, poor communication, Written wrong on the MAR. Lots of info and helps by having the person finding be a part of the solution. Of course there is a place for suggestions. It breaks my heart to have a med error come in as I remember having them. LTC is hard with the amount of meds to give. I also helped my nurses by doing a study of the actual number of doses given in a month and the rate of erros was .002% or some infinite number like that. However the focus is not on the employee but the process. We try to correct the problem that caused the error, and yes many times it is not actually checking the MAr against the label with every dose. So several of those would lead to termination.

GLORIAmunchkin72 · Feb 28, 2006

to me the biggest causes of med errors in ltc is constant disruptions (i'am not even going to go there), and the race to be time-compliant when you have so many residents to give meds to. to send the nurse to get more education does not fix the problem because it isn't the problem in most cases.

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. 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.

Vision Healthcare · Sep 18, 2006

Does anyone know where I can get a good education sheet that would inform my nursing staff on how NOT to make med errors? Please let me know I need to inservice my staff and would greatly appreciate any info anyone can give me. Thank you.

Vision Healthcare · Sep 18, 2006

Do you know where I can get a education sheet to help with some of my staff that have made med errors. Please let me know. Thank you.