Drug errors

oncnurse · Jun 19, 2000

I am so glad that I saw this discussion, because as a manager of a large oncology unit, I have seen an increase in med. errors. Yes, there are many diversions out there, but I feel that giving medications is a huge responsibility that deserves the utmost in concentration and accuracy. I would like to give a short inservice just to review the 5 R's. Does anyone have any suggestions as to what tools would be good. I don't want to insult the integrity of the nurses, because they are awesome, but I do see the incidence of errors increasing.

Thanks.

bunky, BSN, RN · Jun 23, 2000

Here is just a thought on this. We are currently reprinting and checking our MARS daily. What about the incidence of computer generated pharmacy errors that this causes? If we were to take a step back and go back to having MARS that lasted for a few days, with new meds being hand written in, it'd be easier for the nurse to check each night, and it may eliminate errors because we've cut out the risk of computer error significantly. Just a thought as we spend a large part of our night shift going over EVERY single med on the new MARS. I'd say that once a week I find a med on someone that was never ordered, and always added by pharmacy computers.

leem · Jun 26, 2000

Clearly you or a loved one has not been the recipient of such an error. Feeling "bad" is little recompense when an error has been made which causes injury; particularly if this is because the nurse was just not paying close enough attention to what they were doing.

I understand that the pressures of understaffing present a difficult situation, nevertheless, if an error has caused injury, then I think some form of punishment is approriate. The case in which an error has caused no injury may certainly benefit from counseling.

However, I do think that if an error can be traced to management that has established a pattern of understaffing, thereby makeing such demands on there workforce that the health and safety of those whose care they are entrusted with is endangered, then I think it not inapproriate that they (the management) should be held liable, with civil and criminal reprecussions. These reprecussions should not only extend to the corporation but also to the individual managers.

Or, as an alternative, the injury they have caused be inflicted upon them.

Been There,

Lee

Originally posted by chrisgidney:
Do you think that nurses who make drug errors should be punished? Often in the past this has been the case but things are changing (well in my work area anyway). Nurses involved in drug errors often feel bad enough about the whole thing as it is.
Is counselling the best way?
What do you think?
Looking forward to hearing your comments.
Regards
Chris

leem · Jun 26, 2000

Originally posted by Anthony Marc:
I am not surprised to observed
each of the respondents, including Dr.
Lucien Leape's failure , to recognize an extremely fundamental cause of medication errors: the Human factor. The Human.. to whom the responsibility for the safe administration of assigned medication was given. It is basically misguided to suggest,conclude or identify ANY established procedural entity,relevant to the administration of drugs by a Nurse,as the culprit! If one was truly alert to the realities around oneself as pertains to medication errors... one recognizes, beyond a resonable doubt,that the causative factor
was (to put it simply) the FAILURE one of the Nurse to successfully confirm,satisfactorily, the 5 R's associated with the safe and effective administration of said delivery of the assigned medication.

Punitive: Do you suggest we reward one for
ineffective administration of medications? I suggest one ought to be rewarded with the
reality that, subsequent review which demonstrated, on the part of the RN, a lack of knowledge and/or a lack of an ability to construct logic from
established principles relating to processes of safety, would result in a review of his/her competency by the Licensing Authority. I truly get tired of one always
attempting to find some elusive pseudo-construct toward identify acts of incompetency as a "norm" . It is truly no wonder why such acts continue, given that
type of support.

[This message has been edited by Anthony Marc (edited December 20, 1999).]

Ditto!! Well said!!!!

ICUNurse · Jun 26, 2000

Originally posted by chrisgidney:
Do you think that nurses who make drug errors should be punished? Often in the past this has been the case but things are changing (well in my work area anyway). Nurses involved in drug errors often feel bad enough about the whole thing as it is.
Is counselling the best way?
What do you think?
Looking forward to hearing your comments.
Regards
Chris

Yesterday I made a drug error. I have been qualified nearly 9 months and have worked on ICU since then. My patient was a neuro patient who had no CVP line in, just an arterial line and on analysing his gases it was noted that his potassium was low. He had no potassium prescribed so I asked the Dr if he wanted to prescribe some. The Dr had been present when I had just aspirated one litre of bile etc from the patient's distended stomach, so I assumed that the Dr realised that we could not give potassium by the nasogastric route. Another nurse checked the IV infusion of 40mmol potassium which I put in the usual 50 ml bag of normal saline and then I gave it peripherally!

On handing over my patient to the next shift, I told her of the potassium being unable to be given by the NG route and she informed me of the error.

I feel so bad. The patient's arm with the peripheral line was in fact unharmed, but the nurse in charge filled out a 'Critical Incident form' and spoke to me about my mistake.

Today I went on shift and was told that I must now be reassessed on my IV usage and this also applied to the more senior nurse who checked the potassium. I pointed out that the nurse who checked the potassium had not looked after my patient and wasn't aware that he had no central line. I feel that it was my responsibility to have informed her of that fact, so feel very sorry that she is also being punished.

The assessment can take weeks or even months on our unit and I feel utterly demoralised. Of course I should have known. The awful thing is that just one week ago the same patient was given potassium peripherally by another fairly new nurse on my unit. So two other nurses are also being publicly shamed. I wish that this information had been passed to me after the first mistake. As it is, I have to provide a statement of what I did and will have to see the Directorate Manager and explain my actions.

Yes I did wrong, but it was a genuine mistake and I am extremely upset about it. I feel that I truly feel so bad about it, that being punished for weeks or months is just so punitive.

If it had happened to my relative I would be angry, but for the same thing to happen twice, I think I would also feel angry at the Unit for not passing on the need to be careful about potassium administration to all staff.

Sometimes people assume we know things when we don't. I knew about the dangers of inotropes being given peripherally. Can anyone give advice about other drugs that must not be given peripherally, please?

[This message has been edited by ICUNurse (edited June 26, 2000).]

ClariceS · Jun 27, 2000

Originally posted by oncnurse:
I am so glad that I saw this discussion, because as a manager of a large oncology unit, I have seen an increase in med. errors. Yes, there are many diversions out there, but I feel that giving medications is a huge responsibility that deserves the utmost in concentration and accuracy. I would like to give a short inservice just to review the 5 R's. Does anyone have any suggestions as to what tools would be good. I don't want to insult the integrity of the nurses, because they are awesome, but I do see the incidence of errors increasing.
Thanks.

I recently used an article inservice that my nurses read and did a 10 question test about Med errors. It did help bring it to the forefront of their thinking again. It is by PEAK Development resources. They can be reached at [email protected] or at

Peak Development Resources, LLC

P.O. Box 645

Midlothian, VA 23113

Maybe this can help. It covers the 5 R's, definition of a med error, and proper reporting of med errors.

snickers · Jun 27, 2000

dear ICUNURSE:

From a Canadian perspective(British Columbia).

We hang kcl in peripheral iv's all the time.....I think that mmol's=Milliequivalents, hence,40 meq, is not an unusual amount to give, but we generally hang it in a litre of sol'n...D5w or code 8. There have been many times that i have hung kcl in 100cc add a line and it is given periperally(slowly),Anything over 20 meq's must be on a pump.

Don't beat yourself up....just look at it as a learning experience...you won't ever do it again. Just wanted to let you know that what you did in the UK, would have been quite fine here in B.C.

Do you have drug manuals on your unit? We refer to ours as the "Blue Bible"

sj.

mcl4 · Jun 27, 2000

Originally posted by hmt:
I have witnessed a different kind of drug error; what do you think about 'punishment' of this incident (more and more common now)..
I see Nurses that poory spike TPN bags, thus spillage/leakage/waste of the entire bag occurs. What do you feel is a punishment of this med error/incident costing $700-$1200 +
per bag.

mcl4 · Jun 27, 2000

Originally posted by hmt:
I have witnessed a different kind of drug error; what do you think about 'punishment' of this incident (more and more common now)..
I see Nurses that poory spike TPN bags, thus spillage/leakage/waste of the entire bag occurs. What do you feel is a punishment of this med error/incident costing $700-$1200 +
per bag.

I have not seen this happen. Is this the same nurse consistently spiking a bag which would need to be wasted, or is it a general trend with the entire staff having problems spiking a TPN bag.

My reaction to your message is no, the staff nurse shouldn't be expected to cover this cost and I do not see this as a medication error.

JillR · Jun 29, 2000

ICUnurse,

I don't quite understand the problem here. We administer potassium all the time throught periphereal IV's. We use liter bags though. Is it the concentration of the potassium thats the problem? Sorry but I just want to get this straight. I am assuming that the concentration of the potassium is irritating to the veins? Could you please enlighten me. Thanks. JillR

ClariceS · Jun 29, 2000

We also almost always admin KCl through peripheral IV's but we also ALWAYS put it on a pump. We try to dilute it well (eg. 20 mEq in 250ml NS or more) to decrease patient discomfort and we run it slowly.

Nancy1 · Jun 30, 2000

It is difficult to understand all of the steps that are involved in one medication error. I was fortunate to have a DON who used any error as a teaching opportunity so we could all learn from mistakes, and hopefully prevent that mistake from happening again, as it did in the situation being discussed.

Perhaps if nurses would bring this up at staff meetings more management would use this method.

NA