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Discussion

Nurse Practice Act Question

Hi all,

I am an associate degree RN taking RN-BSN classes and I have a question that I hope someone can help with. If an RN takes out a vial of insulin that is outdated and over the course of 10-15 minutes gives 5 people injections, she/he doesn't ever put the vial in the fridge, so they have only checked the label once. Is that 5 medications errors incidents or just one since they were drawn up at or around the same time? I have tried to find this information but I have a hard time understanding the lingo in the Nurse Practice Act book I am looking things up in. Thanks for any help you can give me.

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Patients have 5 rights. right patient, right med, right dose among them the fact that they are outdated is the wrong dose/ med and 5. injections to 5 people is 5 med errors. the only combining that you can do is combining the wrong dose/med with the person given it to.

It is one medication error but you would have to write 5 different incidents errors. In doubt it really depends on the facility protocols and above all the pharmacy. It also depends on where you work LTC or Hospital. In doubt ask your boss.

Good luck

5 errors.

5 errors... yup

i presume this is homework, or you should have stopped the nurse from doing this.....

Every person being an individual, with an independent medical record would need a seperate and individual incident report.

Tait

  • Author

yes Morte it is a scenario that I am trying to address. My classes are online and the only book I have to work with is the Texas Nursing Practice Act which is not an easy read. The question I am trying to determine is whether to report that nurse to the BON, or does this fall under the minor incident rule which states you can make 5 errors before reporting to the board. I think it is reportable due to the risk of harm it could cause. I just didn't know if since she didn't put the vial back in the fridge and pull it out each time, would drawing up 5 syringes be considered 1 incident or 5. I think it is 5 but I just want to be sure I am correct with my line of thinking.

  • Experts

The nurse gave five different injection of outdated insulin (to five different clients, although I would consider it the same if she gave one client multiple injections from the vial of outdated insulin), so I would consider that five separate errors.

"The question I am trying to determine is whether to report that nurse to the BON, or does this fall under the minor incident rule which states you can make 5 errors before reporting to the board."

I have never heard of the "minor incident rule, but this is a major error, what if the insulin wasn't effective?? what if the sugar isn't checked in a timely manner? Do you have a 2 person check in place for insulin?

  • Author

Thanks for your comments, the "minor incident rule" is part of the Texas Nursing Practice Act, it is rule 217.16. This is a homework assignment and I am having a hard time wading through the legal speak. Under 217.16, if you have less than 5 minor incidents in a 12 month time period, the peer review committee doesn't have to report you to the BON so my question really was this: if a nurse removes a vial of any medication, checks it once and fails to note it is outdated and proceeds to draw up and give that medication to 5 pts, is it only one incident since she only checked the vial once or is it 5 incidents because she should have checked the vial before drawing up the medication for each patient?

It's five incidents. Each improper administration is an incident. I don't know how someone would know another nurse did what you are being asked about, though, unless you were following her around.

Generally, if you find a medication error, as a nurse on the same or following shift, you don't generally report it to the BON. You do an incident or medication error report which goes to your manager, who follows up on it and reports it as necessary.

  • Experts

i went to the website of the texas board of nursing and looked at both the nursing law and the rules and regulations. http://www.bon.state.tx.us/nursinglaw/ - texas nursing laws. there is nothing specific in the law that will help you decide whether the scenario you were given are medication errors. i would answer your question as a "no" insofar as it being a violation of the nursing law. now, this rn has probably violated her facility policy and procedures in some way and incident reports should be made out, but there is no way of knowing what those policies and procedures are except that good nursing practice pretty much guide what most facility policy and procedures are. laws tend to be more on the vague side and things get more specific as you get down to individual places.

there is a position paper on medication errors on the texas website: http://www.bon.state.tx.us/practice/position.html#15.17:

15.17 texas board of nursing/board of pharmacy, joint position statement, medication error

medication errors occur when a drug has been inappropriately prescribed, dispensed, or administered. medication errors are a multifaceted problem which may occur in any health care setting. consistent with their common mission to promote and protect the welfare of the people of texas, the texas board of nursing and the board of pharmacy issued this joint statement for the purpose of increasing awareness of some of the factors which contribute to medication errors. the boards note that there are numerous publications available which examine the many facets of this problem, and agree that all elements must be examined in order to identify and successfully correct the problem. this position paper has been jointly developed because the boards acknowledge the interdisciplinary nature of medication errors and the variety of settings in which these errors may occur. these settings may include hospitals, community pharmacies, doctors' offices/clinics, long-term care facilities, clients' homes, and other locations.

traditionally, medication errors have been attributed to the individual practitioner. however, reports such as the recently published institute of medicine's "to err is human: building a safer health system," suggest the majority of medical errors do not result from individual recklessness, but from basic flaws in the way the health system is organized. it is the joint position of the boards that a comprehensive and varied approach is necessary to reduce the occurrence of errors. the boards agree that the comprehensive approach includes three major elements: (1) the individual professional's knowledge of practice; (2) resources available to the professional; and (3) systems designs, problems and failures. each of these three elements of this comprehensive approach are discussed below.

professional competence has long been targeted as a source of health care professional errors. to reduce the probability of errors, all professionals must accept only those assignments for which they have the appropriate education and which they can safely perform. professionals must continually expand their knowledge and remain current in their specialty, as well as be alerted to new medications, technologies and procedures in their work settings. professionals must be able to identify when they need assistance, and then seek appropriate instruction and clarification. professionals should evaluate strengths and weaknesses in their practice and strive to improve performance. this ultimate accountability on the part of individual practitioners is a critical element in reducing the incidence of medication errors.

the second element (resources available to all professionals) centers on the concept of team work and the work environment. the team should be defined as all health care personnel within any setting. health care professionals must not be reluctant to seek out and utilize each other as resources. this is especially important for the new professional and/or the professional in transition. taking the time to learn about the resources available in any practice setting is the individual professional's responsibility, and can help decrease the occurrence of medication errors. adequate staffing and availability of experienced professionals are key factors in the delivery of safe effective medication therapy. in addition, health care organizations have the responsibility to develop complete and thorough orientation for all employees, maintain adequate and updated policies and procedures as guidelines for practice, and offer relevant opportunities for continuing staff development.

analysis of the third element (systems designs, problems and failures) may demand creative and/or innovative thinking specific to each setting as well as a commitment to guarantee client safety. systems which may have been in place for a long period of time may need to be re-examined for effectiveness. new information and technological advances must always be taken into account, and input should be solicited from all professionals. in addition, the system should contain a comprehensive quality program for the purpose of detecting and preventing problems and failures. the quality program must encourage all health care professionals to be alert for problems encountered in their daily tasks and to advocate for changes when necessary. in addition, the quality program should include a method of reporting all errors and problems within the system, a system for tracking and analysis of the errors, and an interdisciplinary review of the incident(s). eliminating systems problems is vital in promoting optimal performance. the table on the following page, while not an exhaustive list, specifies areas which can be reviewed when medication errors occur. these areas encompass all three of the aforementioned contributing elements to the problem of medication errors and can be applied to individuals or systems. communication is a common thread basic to all of these factors. effective verbal or written communication is fundamental to successfully resolving breakdowns, either individual or system wide, that frequently contribute to medication errors.

the boards agree that health care regulatory entities must remain focused on public safety. it is imperative that laws and rules are relevant to today's practice environment and that appropriate mechanisms are in place to address medication errors. the complex nature of the problem requires that there be a comprehensive approach to reducing these errors. it is vital to the public welfare that medication errors be identified, addressed, and reduced.

(board action 10/2000)

(reviewed - 01/2009)

references

institute of medicine. (1999). to err is human: building a safer health system. washington, d.c.: national academy press.

joint commission on accreditation of healthcare organizations. (1999). high-alert medications and patient safety. sentinel event alert, [on-line]. available: jcaho.org/edu_pub/sealert/sea11.html.

leape, l. l. (1994). error in medicine. journal of the american medical association, 272(23), 1851-1857.

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