Nurse Distractions and Med Errors please share input

CNOR1988 · Mar 4, 2010

I have found some interesting articles using ProQuest. I tried using CINAHL database but I couldn't get access without purchase. I have found that medication errors can happen at any time between prescribing and monitoring after administration. I also found there are different types of distractions including between task, mid-task distractions, and system failures. I have also learned through my instructors that it is important to be honest and report the incident to prevent further mistakes from being made, getting the appropriate treatment for the pt, and that system failures can be fixed to prevent errors from occurring in the future. An example of not filling out an incident report that I heard from an instructor was; a nurse once gave an elderly pt at a nursing home a whole different patient's medications and instead of reporting it and calling the MD she gave the pt all of his/her own scheduled meds on top of the other ones. The pt's BP dropped significantly was transfered to the hospital and died.

Moogie · Mar 4, 2010

I have found some interesting articles using ProQuest. I tried using CINAHL database but I couldn't get access without purchase. I have found that medication errors can happen at any time between prescribing and monitoring after administration. I also found there are different types of distractions including between task, mid-task distractions, and system failures. I have also learned through my instructors that it is important to be honest and report the incident to prevent further mistakes from being made, getting the appropriate treatment for the pt, and that system failures can be fixed to prevent errors from occurring in the future. An example of not filling out an incident report that I heard from an instructor was; a nurse once gave an elderly pt at a nursing home a whole different patient's medications and instead of reporting it and calling the MD she gave the pt all of his/her own scheduled meds on top of the other ones. The pt's BP dropped significantly was transfered to the hospital and died.

That's something I hate about the electronic databases. You might find the perfect article for a paper, only to learn that it costs $30 or more to download the thing. I won't do that just for one paper---maybe for a thesis or dissertation but not for one paper. I am too cheap. :uhoh3:

That is a very sobering story about what can happen from not admitting to a med error. In some facilities, there's a mindset that completing an incident report means that one is a "bad" nurse. An incident report should never be viewed as punitive; it's a learning experience and a way to track trends in errors, as you are seeing from the anecdotes posted here and from what you've found in the literature. Unfortunately, in the case you described, the patient paid the ultimate price for the nurse not being upfront about making an error. (BTW, do you know if the nurse faced any consequences?)

Good luck on your work; it sounds like you have chosen a topic that is very relevant and useful to nurses in all sorts of practice settings.

CNOR1988 · Mar 4, 2010

I am not sure what the consequences were for that nurse.

Moogie · Mar 5, 2010

I am not sure what the consequences were for that nurse.

I would hope that he/she was disciplined by the facility. Again, not that an incident report should be considered punitive but because the whole act of covering it up was wrong on so many levels. Unfortunately, there are far too many people who adhere to the CYA mentality.

Very sad and very unnecessary. (But thanks for sharing the story---it is obvious you have learned from this nurse's mistake and I think everyone who hears this story will also take pause...)

FowLaf24/7 · Mar 5, 2010

One medication error, which was caught prior to the administration of the IV push medication, occurred when two nurses were attending to the same patient. One nurse was taking care of the scheduled dose of a medication, and another nurse had placed a vial on the same table. This vial contained a medication which could been drawn up PRN . The two nurses were D/C a catheter line, where direct pressure would need to be maintained for 30 minutes. The nurse drawing up the scheduled dose begin with the insertion of the syringe needle into the PRN vial, when she decided to ensure it was the correct medication. Upon seeing the wrong medication, she withdrew the syringe needle. :idea:

sasha2lady · Mar 5, 2010

i once gave a PPD to a resident who was "allergic" to it. I checked for allergies but didnt see the PPD allergy on the mar because it had been written in with pencil..which is a no no to start with. It had faded from something being spilled on it and wiped off. I only realized it when i went to her chart and seen the allergy listed on the front...in ink. I was so embarrassed..Id only had my license for 2 days, the nurse who was training me didnt know she was allergic to it either..we both looked and missed it. The site itself didnt even turn red or anything so I dont think she had a true allergy to the PPD. The most errors I have seen are transcription type errors, orders not being put on the MARs or tx record or in the lab books. The worst is at changeover. I missed one last month myself, a resident was put on scheduled tylenol in the am and at hs....I got so overwhelmed because the boss told the other nurses they didnt have to worry about doing their assigned mars because the "night nurses would do it" so I had my regular 8 plus 60 others. I got in a hurry because i had 2 days to work on them. I absolutely will not do that again. They can either do their own or they will have med errors to fill out next month.

belgarion · Mar 5, 2010

In some smaller facilities like the one where I work things are still a little old fashioned. We keep each patient's meds locked up in a box in the patient's room (except for the controlled stuff and some OTC meds).

In some ways it makes it easier. You pretty much have to take the MAR or the COW into the room so you can check off each med as you select it. The meds are segregated by pt. so you aren't as likely to give the meds to the wrong pt.

The downside is that you are trying to sort out the meds while the patient, family members, the TV, and a dozen other things are competing for your attention. Also, you better hope that whoever pulled the meds from the pharmacy was paying attention. As with everything else, complaceny will bite you right in the gonads.

RunningRNBSN · Mar 5, 2010

I worked with a nurse who told me of a potentially fatal med error -- many years ago he was watching another nurses patients while she had her lunch. The nurse who was on lunch asked the covering nurse to start an antibiotic. She told the covering nurse that the antibiotic was in a syringe on the patients back counter and could be run over 20 minutes (I work in a Peds ICU and thus most medications come in a syringe from pharmacy).

Anyways, he said he went into the patients room and grabbed the large syringe off the back counter, put it on a syringe pump and started it to run over 20 minutes. Approximately 5 - 10 minutes later the patients parents ran out of the room saying their son couldn't breathe and was becoming unresponsive. The nurse ran in there and found the child barely responsive and not really breathing.. he immediately bagged the child and yelled for someone to call the intensivist. The physician ran into the room and asked the nurse what he had done (the child was stable and no clinical reason why he should have changed all of the sudden) and as the nurse was telling the doctor that he started an antibiotic, another nurse went to turn the antibiotic off and found that he had started FENTANYL!! As most know, Fentanyl causes chest rigidity when pushed fast or in large doses. They pushed narcan and the patient was fine.

Apparently he said he was so busy with his own patients and when he went to start the antibiotic for the other nurses patient, the parents of the patient were asking him questions and he got distracted and didn't even look at what medication he was starting.

Ms.RN · Mar 5, 2010

I hate when two patients in the same room have same first name or very similar last names. I triple check their ID band.

Our unit manager does the renwal MAR for the next month and every month floor nurses find mistake after mistake of transcription error, patient is on potassium when there is no order for it, medications not put on the new MAR etc.. Because we floor nurses give medications everyday we know what medications are missing by looking at it. I asked unit manager if floor nurses can do the renewals and she said she have to do it becuase some of the floor nurses are not being careful... What? :nuke: :banghead: :eek:

lisamc1RN, LPN · Mar 5, 2010

Two stories. I was fresh out of nursing school and I had my supervisor telling me to go give pt X his morphine because he was badly dyspneic and needed it asap. She had the MAR, as she was adding new orders. She told me the dose, I went and gave it. I went to sign it, and she had told me the wrong dose. Of course I got a write up and had to fill out an incident report and learned a very valuable lesson. The patient was not harmed, but still. Do you think I will ever give a med based on another nurses word again?

Second story happened just the other day. I received report from the off going nurse that she had to insert another sub-cutaneous button because the dose of medicine that the patient needed had been increased and would require two sites to push now. We did count and she indeed did use 1.5 vials of a very powerful narcotic on this patient. I went to do my own med pass and found that the order ready one tenth of the amount that she had pushed. I immediately ran to my patient, who was barely breathing. Narcan was pushed and the patient recovered just fine, but it was a huge error and an alarm should have gone off in my head when she stated that she needed 2 sites when I have never, ever pushed that much narcotic sub-q before. The nurse was overwhelmed and distracted that night, and she had converted mg to ml in her head and have given 10 times the amount of narcotic ordered, not once, but twice. Thankfully, the place that I work is not punitive. She had a 3 day suspension and is retraining with our education department. She is a good nurse who got distracted on a very busy night.

tobesmartt · Mar 5, 2010

Wow..I really need to concentrate more . Apparently we nurses get distracted . I think cause we have so many things at us. After all we are super people. :no:

asfreeasabird · Mar 5, 2010

I was just about to leave for lunch when the gastroenterologist called me with a new order to prep a patient for a colonoscopy. I ran to the chartbox of the room number he told me wrote all the information down and headed to lunch. I started the bowel prep, and wondered if he had given me a wrong room number. I looked through the charts to see which one of my patients needed to have a gastroenterologist, and didn't find anything. I called the gastroenteroloigist back and he gave me the right room and the wrong patient. I ended up spending my afternoon bowel prepping two patients. The patient I accidentally preped had a suspected small bowel obstuction and had not had a bowel movement in several days. I called her attending physician who laughed. I am just thankful it was not a cardiology consult.