Nurse Distractions and Med Errors please share input

[CNOR1988]

Hello everyone,

I am doing an evidenced-based research paper for my advanced clinicals on nurse distractions and medication errors. I would appreciate any personal stories or input on this topic. Thank you :)

[RNperdiem, RN]

A couple of weeks ago I was talking to my nurse manager.

I was standing in the patient room drawing up an ordered dose of Lasix for my patient. The manager was standing outside. While talking, I drew up the dose, checked it and in my distracted state, dropped the whole syringe in the sharps container without giving it to the patient.

Maybe this is not exactly a med error, but it shows what distraction can do.

[Meriwhen, ASN, BSN, MSN, RN]

I made a med error due to distraction. I had noticed that a medication was d/c for a patient and so I didn't pull it...but the unit was crazy that day (no pun intended) and we were overwhelmed with putting out all the fires...and when it came time to get this patient's medications, I pulled the d/c'ed med and gave it to him. I realized the mistake 5 minutes later when I saw my meds were off by 1.

No harm, no foul to the patient, which was good...still, it was a med error that was my entirely my fault--when I'm passing meds, I should have not let myself be distracted, and I did. I've been more strict with myself since then--when I'm passing meds I tell the staff not to interrupt me unless it's a bona fide emergency. It's hard to enforce that rule some days...but I'm not making the same mistake twice.

[Ruby Vee, BSN]

i once hung a heparin drip instead of lidocaine because i was answering a student's questions when i should have been paying attention to what i was doing. i spiked the lidocaine on the heparin tubing, too, but that wasn't as serious an error. the worst thing is, i didn't catch it; the next shift did.

[rockenmomRN]

wow ruby, thanks for your honesty!! i once had a patient who had a bp of 186/115, i was being pressured to get the turn team started (don't even ask what that is), anyhow i went straight for the PRN meds rather than see that he had a scheduled midnight metropolol due at midnight. It was ok b/c it was still the right med, right time reason, you know the drill. pluse he was exhibiting s/s of fluid overload so the lasix was a good thing and when i was done turning the other patients his vitals still warranted giving him the metropolol. thats my story.

[klone, MSN, RN]

A few years ago, I was in charge, and the night was completely chaotic. I was rushing around, putting out fires most of the night. The nursery nurse asked if I could take some colostrum into a mom's room and help her fingerfeed her baby. The syringe with the colostrum had been pulled from the fridge and placed on the baby's bassinet. I brought the bassinet into the mom's room, and she asked if I could fingerfeed the baby while she went to the bathroom, then she would put the baby to the breast after I was done. It was a tiny amount of colostrum, in a subQ syringe, I think probably 1/2ml total. Baby ate it in less than a minute, and as I went to throw the syringe away, I saw the label on the syringe was for a different baby. The baby's nurse didn't check the label, and neither did I.

I wrote up an incident report, emailed my manager, and contacted the ped. I also told the mother, which was the hardest thing in the world to do. It was sad, because prior to that we had a really nice rapport, and I knew she was very upset at me. The ped spoke with the mother the next day, and after reading the other mother's prenatal labs, told the mother that there was nothing for her to worry about.

What a horrible lesson, but I got off cheap.

[StNeotser, ASN, RN]

I think many med errors on my unit are due to the layout. We have a desk that is in the middle of public area (it isn't really a nurses station) where patients and family members can just come up to, med carts are in hall ways where family members and patients can just walk up to. There isn't any private area aside from the med room (which of course doesn't have a chair in it) The door to the med room more often than not is propped open and shouldn't be. The reason it is propped open is because they only give one nurse a key. The pyxis is in the med room, so whatever I am doing at any time, priming tubing, drawing up insulin, pulling narcs I am meant to be "available" to family members and patients.

I'm pretty sure if I was a visitor I'd at least wait until the nurse had finished drawing up a syringe before I started in with "My mother needs..............."

[makes needs known]

I just listen to my mp player while I work, can't hear anything except the music. :)Just kidding, I would get fired. But I do listen to the voices in my head:) The voices say try to focus, even if everyone tries to distract you:)

[2be1nurse]

I am a student nurse but I have expereinced some distractions from nurse when I was trying to concentrate on my medication

[midinphx, BSN]

A nurse I worked with once gave Rhogam to the wrong pregnant patient. It was in the ER and the nurse went to give the Rhogam which we had been waiting for since it is a blood product. The nurse went to give the shot to the patient in room gyn2. Someone else needed that room and the patient had been moved somewhere else. The irresponsible nurse didn't bother checking the arm band or the label and gave another patient (who was also pregnant the shot). Talk about paperwork! To make it worse the nurse blamed the incident on the ERtech for moving the patient, even though she had been told to do so by the charge nurse.

Take home message: check your name tags! (I'm CCU with only 2 patients and I am one of few nurses who take the MAR in to my room and check bands).

[Moogie]

Interesting topic! What have you found in the peer-reviewed literature? You might want to look at the CINAHL database for prior research done in this area.

[CNOR1988]

Thank you everyone that has responded so far for your time and honesty about being distracted and making medication errors. Great ideas on how to prevent this; checking arm bands, checking med labels, having appropriate medication rooms with access, and just taking the time to focus on what task is being done even if it means excusing yourself from a conversation for the saftey of the pt. Thanks again, your experiences are interesting and much appreciated :)