Peer Review at work...advice please!!

[brockclan3]

I have been a nurse since January and working since February. Since then I have had 5 med errors since beginning my hospital job. Two errors that were administered to two patients but, fortunately, did not result in patient harm. The other three were errors that were caught by other nurses before administered. I don't want to go into alot of detail, obviously for privacy. I have been informed that for the time being, because of the 'trend' of mistakes, I am not allowed to give any meds and that I will go before a peer review in the near future. I was told the purpose for this was to determine if I can continue nursing, as in giving meds, or start fresh in another department, ect. But in my research, most of the time peer reviews are performed to decide if I will be reported to the BON for unsafe practice. Has anyone else experienced a similar situation? What can I expect? Will this be as brutal as I am expecting it to be?

[guest358111]

The interesting piece here is the wondering "where the disconnect is."

I can offer a perspective from my time spent orienting nurses with varying levels of experience/credentialing....take it for what it is worth.

What I have seen with errors is often the person is doing the 'task' of medication administration without realizing the disconnect is with the 'thought' of medication administration.

It gets tricky and seemingly hard to 'nail down' when the person is used to speed and efficiency and the muscle memory of the task (and is good at it!), but not necessarily the 'thought' piece.

I don't know what your errors were/are, but one example to demonstrate what I am saying is: being in a rush, pulling medications from the Pixis or whatever for patient A, and walking over and giving it to patient B because 1. It is emergent so you were focused (even if you didn't realize it) more on task of pulling it quickly and giving it quickly rather than the thought of does this make sense...also # 2. there is not built into your thoughts and tasks an ingrained, same way every time method of administration where the name and date of birth are checked EVERY time, before giving someone anything that they will swallow and maybe even 3. it was not scanned specific to the patient (bedside verification) because the seemingly urgent task of giving this is overriding the more appropriate thoughtthat this needs to be scanned, urgent or not.

I have seen this often in folks who were trained in acting in emergent situations before they had a base built in their muscle memory of giving medications slowly and thoughtfully, with the mental checks needed built in about the 5 rights happening the same way every time.

I don't know if any of this applies to you but I am just trying to assist with some observations.

In other words, if you don't train your brain to slow down and say to you while you are in the middle of the task of medication administration: to think is this for the right patient and does this make sense, and is this the right drug in my hand and is this the appropriate dose based on what is happening with the patient in front of me? each and every time you give meds, errors will happen.

If someone says "Please give this med" and you just do the task of giving it, mistakes will happen.

I am confident that if this is anything like what is going on with you, you can fix it.

But you have to train your brain to think differently and override inbuilt incorrect medication administration habits that you have that are causing errors.

I should also note that in my experience, taking more courses, for example in pharmacology do not often help this. You can always look up a medication that you don't know. Rather you need to create a checklist in your brain that you follow the same way every single time you administer a medication-regardless of the situation. If you have mental safety checks (or even a paper checklist) built in that matches with your muscle memory of the "task" of medication administration, you will be safer. Basically you will need to go back to medication administration 101 and retrain how you think about administering all medications.

I wish you all the best!

[beekee]

I'm going to agree with the previous poster - a pharmacology class isn't going to help you (unless your med errors stem from not knowing when to hold meds).

You were a good student, so the basics are more than likely there. It's probably a disconnect between your brain and your actions. Slow down. Be deliberate. Heck, write our the medication rights (however many you learned...I've seen 5, 6, 8...) and check off each one each time you give a med until you develop some "muscle memory."

[Miss.LeoRN]

The first issue is... identify what mistakes you are making, then define how you're making them. Without that information you're going to keep making mistakes. We can't give you much help since you're not elaborating on what mistakes you've made or your near-misses; which I don't quite understand why you're not willing to share considering you've already given a very descriptive encounter about vanco-gone wrong. Honestly, we can give you more advice and more help if we don't know what is going on.

To be honest... it doesn't matter how good you were in school or what grades you had, how stellar you were in clinical. None of that matters anymore. You're not in school. You're on the floor now. There's no one over your shoulder anymore.

All I can really say is to start peer checking yourself. You're surrounded by coworkers right? It's as easy as "Hey, I know you're busy, but can you double check this for me." There are certain drugs at our facility that require dual verification. Others do not, and some nurses feel that they should. For an example; insulin. Where we are, it's not required, same for a Heparin bolus, or things like IV ativan (though you need a witness to waste); we will ask for a peer check (we use Cerner, which allows a cosigner even if not required).

[brockclan3, LVN]

Here is the list unsafe practices that is up for my peer review (it is alot): 1) When I first started work (ED) I was assisting another nurse in starting an IV and NS fluids. The nurse asked for a J-loop; I attached it to the saline flush but I did not flush it because I assumed she would do it. Same with IV tubing and the bag of fluids. One of the first things I learned in school is to prime the line and the flush. I knew how dangerous air in the line is. My mistake is assuming the other nurse would do that. 2) order for a patient was for fentanyl and I gave morphine (morphine had already administered previously). My mistake was not double checking the order. 3) I had inserted a foley and withdrew a urine sample from the port. My mistake is that I withdrew from the bulb inflation port instead. I placed it in a cup ready to send to the lab and another nurse commented how clear it was. When she said that, I realized what I had done. I threw out the sample, re-inflated the bulb, and collected the urine correctly. 4) the vanc incident (read my last post about this because there were other factors involved). My mistake was was not checking with the nurse and the order to verify what was in the bag before I attached tubing. 5) I figured a pediatric dose of Benadryl incorrectly and another nurse caught it before I administered it. I was going too fast and did not recheck the dose. 6) I used the wrong syringe to draw up insulin...I used a TB syringe instead. Thankfully my supervisor was there when I drew it up hoping I would realize what I had done. I did not and she pointed it out. I injected the insulin back into the vial, discarded the wrong syringe, and drew it up with the insulin syringe.

I have gone through a second orientation with a preceptor on med administration and it was great. I am a LVN/Tech in the ED. I received adequate orientation on the tech side when I started but minimal orientation on the nursing side. That 6 weeks I did on re-orientation with meds was what I needed and it went very well. But obviously I have a pattern here that scares me about patient safety. Using the 5 (6,7,8) is obviously where I missed the mark.

[brockclan3, LVN]

The interesting piece here is the wondering "where the disconnect is."

I can offer a perspective from my time spent orienting nurses with varying levels of experience/credentialing....take it for what it is worth.

What I have seen with errors is often the person is doing the 'task' of medication administration without realizing the disconnect is with the 'thought' of medication administration.

It gets tricky and seemingly hard to 'nail down' when the person is used to speed and efficiency and the muscle memory of the task (and is good at it!), but not necessarily the 'thought' piece.

I don't know what your errors were/are, but one example to demonstrate what I am saying is: being in a rush, pulling medications from the Pixis or whatever for patient A, and walking over and giving it to patient B because 1. It is emergent so you were focused (even if you didn't realize it) more on task of pulling it quickly and giving it quickly rather than the thought of does this make sense...also # 2. there is not built into your thoughts and tasks an ingrained, same way every time method of administration where the name and date of birth are checked EVERY time, before giving someone anything that they will swallow and maybe even 3. it was not scanned specific to the patient (bedside verification) because the seemingly urgent task of giving this is overriding the more appropriate thoughtthat this needs to be scanned, urgent or not.

I have seen this often in folks who were trained in acting in emergent situations before they had a base built in their muscle memory of giving medications slowly and thoughtfully, with the mental checks needed built in about the 5 rights happening the same way every time.

I don't know if any of this applies to you but I am just trying to assist with some observations.

In other words, if you don't train your brain to slow down and say to you while you are in the middle of the task of medication administration: to think is this for the right patient and does this make sense, and is this the right drug in my hand and is this the appropriate dose based on what is happening with the patient in front of me? each and every time you give meds, errors will happen.

If someone says "Please give this med" and you just do the task of giving it, mistakes will happen.

I am confident that if this is anything like what is going on with you, you can fix it.

But you have to train your brain to think differently and override inbuilt incorrect medication administration habits that you have that are causing errors.

I should also note that in my experience, taking more courses, for example in pharmacology do not often help this. You can always look up a medication that you don't know. Rather you need to create a checklist in your brain that you follow the same way every single time you administer a medication-regardless of the situation. If you have mental safety checks (or even a paper checklist) built in that matches with your muscle memory of the "task" of medication administration, you will be safer. Basically you will need to go back to medication administration 101 and retrain how you think about administering all medications.

I wish you all the best!

This is all so helpful. This is great insight here and I appreciate the information and your encouragement!

[FolksBtrippin, BSN, RN]

It seems like you made 2 med errors and the others were near misses. The morphine was a med error. I can't find your original post about the vanc, but I guess that was the other. Maybe that one was more serious? If you make a serious mistake, own up to it, but do not let folks make a mountain out of a molehill.

Some of this is just stuff you do when you are new. You won't make that mistake again.

You have the right attitude for learning. You will get better with experience. Ask for help when you need it.

[Orion81RN]

It seems like you made 2 med errors and the others were near misses. The morphine was a med error. I can't find your original post about the vanc, but I guess that was the other. Maybe that one was more serious? If you make a serious mistake, own up to it, but do not let folks make a mountain out of a molehill.

Some of this is just stuff you do when you are new. You won't make that mistake again.

You have the right attitude for learning. You will get better with experience. Ask for help when you need it.

I agree. A lot of this was not communicating exactly what the nurse needed you to do (ex. prime the line) I say just ask even if the nurse will have a duh look on her face. Ask ask ask. The real need errors you made, you seem to understand how it happened, and you seem to have learned from them.