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What can we do to change this to prevent errors?

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cafecreme cafecreme (New) New

We have all noted, an example on News even on this board, of some major error that has impacted lives. None of us can imagine purposely making a mistake that could kill someone, but under the right stressful conditions- it can happen.

The ones noted are dealing with drugs given way above dose, the wrong drug given, and even a few caught before happening but have cost nurses their jobs.

This is our career, license, our livlihood, pays the morgtage etc. So I am asking -- is their other things WE as NURSES can ask to have changed to put one more safety net out there?

Think about this--- vancomycin is in about the same shaped bag and same color label as insulin gtt. Versed, diltiazem and antibiotics all about the same size bag and same color label. These are only a few examples.

Our institution keeps saying they are going to get the drug scanners and that hasn't happened yet. :angryfire

I know it is our FIRST and most Important step to dothe the 5 STEP CHECK. Under stress and the right kind of day (or I should say just a zillion things impacting you at once), or day after day high stress load, and the increasing complicated loads that are happening- errors can be made!!

NO ONE is PERFECT:o !!! What should we start to think collaberatively about, for more saftey nets, that would help to protect us or help us catch a mistake from happening? Would be interested in ideas. THink about your institution and what drugs you give- :uhoh3:

Until hospitals acknowledge that adequate staffing based upon patient acuity saves lives and improves outcomes, we're going to see these tragic errors more and more as our patients become sicker and sicker.

And I've said this before, but don't think barcode scanners will eliminate this problem. Sure, they improve safety, however I've seen some pretty impressive errors made when they were blindly relied upon to administer medications.

I totally agree with you on the need for changes with increased acuity and that bar code scanners should not be relied on 100%. What I am saying is-- we are the ones that are out there doling out the meds under these conditions and we know they are not going to change (the conditions) anytime soon.

I am trying to look at physically, practice wise, is there anything we can do to push for to help protect us.

As I stated in the examples: Why are all IV drug bags labeled with the same color? Why do they not label some with different colors to at least designate importance of drug classification? I know it is still up to us to check that label and a pharmacist or tech could use the wrong color label etc-- but just one more safety net under emergent or stressful conditions could make you take one extra look or prevent someone from getting a sedative vs and antibiotic? We just blindly accept this and put the blame back on ourselves or fellow nurses cuz they should have checked!!!! What if the nurse before you hung the wrong bag--

I am just looking for ideas to help us. Hope this explains that.

jb2u, ASN, RN

Specializes in ICU, ER, Hemodialysis. Has 5 years experience.

I agree with Emmanuel Goldstein on this one. Adequate staffing!!! The nursing force is huge. We could in a very short time make this change; however, many nurses continue to complain, but do not get involved with the political side of nursing. Only then will things improve! Even the tobacco industry realizes the potential threat of the nursing force, in a memo from one tobacco company to another, they stated that the BIGGEST threat to their industry would be if NURSES united against them!!!

purple1953reading

Specializes in ER OB NICU.

I think at this point, we have to realize, that WE ARE responsible for giving the right med, at the right dose, at the right time. That is one of the responsibilities of being a nurse, and though time constraints are felt by all of us, we simply have to take the time to check them and to it right. Several years ago, I got called in to a busy L&D unit, where they had floated a RN from med surg, who had previously only worked oncology, and when I got there, she had just mixed enough MAG Sulfate to KILL the mom and baby, and was one step from hanging it!!! PLUS I would never give a med mixed or obtained by another nurse, not because I do not trust my fellow workers, but BECAUSE I AM RESPONSIBLE for giving the med, and checking it. As house supervisor,I was making rounds, and walked in on Morphine Drip, that had been mixed by the pharmacist, by adding ms to a reg. bag of IV fluids, "because he thought it was going to cost too much to use an enclosed, premixed system" like the PCA and it was hanging through a reg. IVAC pump. OF course, I immediately pulled that drip, though no nurse had made note of it from the present or previous shifts. THEN spend too much of my time, having to write up that incident report, try to count and account for the amount still missing, and wasting the rest of the 1000 cc bag of MS. Relying on somebody else or some other entity I don't think will help. We have all the charts, books , checks in place, we just have to do it. Granted, we are thrown every obstacle that exists from too short on staffing,to pharmacists making mistakes before we get the meds. I always check new meds against the new orders, when I receive them, I even have been the one to point out to the nurse who brought me meds as a patient that she was giving the wrong meds to me. This is just a priority for me, and I hope for all nurses.

I understand what you're saying. One of our experienced nurses rapidly pushed a large dose of decadron from a multidose vial that looked identical to our vials of hepflush. Didn't hurt the patient, but it sure made her damned uncomfortable for a bit. Saw an intubation turn into a full blown arrest when dopamine instead of saline was drawn up and flushed down the ETT (anesthesia requested the saline for suction). Again, the saline and dopamine vials were nearly identical and sitting side-by-side in the cart. Have seen flagyl hung instead of premixed heparin, and vice-versa. And so on.

So I do get what you're saying here, but these examples just drive home that we must practice "the 5 rights" no matter what the situation.

One hospital I worked had all the patient's meds (except scheduled drugs) locked in a cabinet in the patient's room. Watching nurses pull meds from a central location and then walk down the hall to administer them has always made me cringe. How many times do we actually get to our destination without being sidetracked into other rooms or by other staff? That is just a mistake waiting to happen. So I was pleased with the meds being delivered to and stocked in the patient's room. But then, that sort of system isn't something that can be implemented easily in most situations.

As far as staffing goes, yeah it may be wishful thinking, but some of it can definitely be addressed now. Eliminating double shifts and mandatory OT, refusing to accept admissions when you don't have the staff to cover them or even closing beds when there is no coverage would go a long way to alleviating the problem.

Adequate staffing is key! Another issue is working 12 hr shifts. While I prefer 12 hrs and more days off, I think it creates safety issues. Both safety issues for the patient and the nurse. For example, as the night goes on and the stress levels remain high, I am more prone to back injuries, ect. You become less focused on the patient and more about "what needs to get done still" before your shift ends. This is not a great thing to admit- but I think we are all a bit guilty of it at times. Sometimes in order to stay sane or prevent burnout, we need to do whatever it takes to take care of ourselves. Many "sick" days are taken due to stress and burnout.

But, when you call in sick because of stress, you're just contributing to the overall problem, and putting your co-workers and patients at greater risk.

So, in summary, having adequate staff, shorter hours, and an emphasis on stress management are HUGELY important in preventing errors and injuries!!

jb2u, ASN, RN

Specializes in ICU, ER, Hemodialysis. Has 5 years experience.

I think at this point, we have to realize, that WE ARE responsible for giving the right med, at the right dose, at the right time. That is one of the responsibilities of being a nurse, and though time constraints are felt by all of us, we simply have to take the time to check them and to it right. Several years ago, I got called in to a busy L&D unit, where they had floated a RN from med surg, who had previously only worked oncology, and when I got there, she had just mixed enough MAG Sulfate to KILL the mom and baby, and was one step from hanging it!!! PLUS I would never give a med mixed or obtained by another nurse, not because I do not trust my fellow workers, but BECAUSE I AM RESPONSIBLE for giving the med, and checking it. As house supervisor,I was making rounds, and walked in on Morphine Drip, that had been mixed by the pharmacist, by adding ms to a reg. bag of IV fluids, "because he thought it was going to cost too much to use an enclosed, premixed system" like the PCA and it was hanging through a reg. IVAC pump. OF course, I immediately pulled that drip, though no nurse had made note of it from the present or previous shifts. THEN spend too much of my time, having to write up that incident report, try to count and account for the amount still missing, and wasting the rest of the 1000 cc bag of MS. Relying on somebody else or some other entity I don't think will help. We have all the charts, books , checks in place, we just have to do it. Granted, we are thrown every obstacle that exists from too short on staffing,to pharmacists making mistakes before we get the meds. I always check new meds against the new orders, when I receive them, I even have been the one to point out to the nurse who brought me meds as a patient that she was giving the wrong meds to me. This is just a priority for me, and I hope for all nurses.

I agree that it IS our responsibility to give the right med; however, it is a proven fact that IF nurses did everything that they are suppose to do by law then there would literally NOT be enough hours in the day to get it done! Just like the study that showed that IF nurses washed their hands the way that they are SUPPOSE to, then they would spend about 1 1/2 to 3 hours a day washing their hands. The fact is, because we can not do everything that we are supppose to, then something has to give. Some people just rely on the med scan system because they do not have the time to look back at every medicine that they are giving in the chart to make sure that it is the correct dose or the correct route or the correct etc etc. If the RN from two days ago confirmed a med and two days later I come in and give that med, but it was suppose to be for something else (but the DR's writing was just scratch and the pharmacist and nurse thought that that is what it said) then I give the med. I too am making a "med error." And so, it would be expected of me to go back every day of everyshift and look from the pt being admitted to my unit to see if any meds were d/ced but overlooked, any routes changed, strengths changed, etc. But of course, it would be impossible to do this every shift on every pt. So, some amount of reliance is called for. I have to trust my fellow nurses. We are taught in school that for every med even if you gave it to Mr Smith at 0800, we are to check the med with the actual Dr's order for the 5 rights check the med 3 times (drawing up, before going to room, before giving) Now some pt's have 20 meds or more. Some nurses have 6,7, or more pts. It is easy to give an impossible task to a nurse and then just blame him/her when the mistake happens, because, hey, it is a fact that it is OUR responsibility to ensure pt safety. We quickly forget that it is also the hospital's responsibility to ensure pt safety and a safe working environment for nurses, too!!!

Several years ago, I got called in to a busy L&D unit, where they had floated a RN from med surg, who had previously only worked oncology, and when I got there, she had just mixed enough MAG Sulfate to KILL the mom and baby, and was one step from hanging it!!! PLUS I would never give a med mixed or obtained by another nurse, not because I do not trust my fellow workers, but BECAUSE I AM RESPONSIBLE for giving the med, and checking it. As house supervisor,I was making rounds, and walked in on Morphine Drip, that had been mixed by the pharmacist, by adding ms to a reg. bag of IV fluids, "because he thought it was going to cost too much to use an enclosed, premixed system" like the PCA and it was hanging through a reg. IVAC pump.

Two more good points. One being we need to refuse assignments outside our level of safe practice. I'd NEVER work L&D. I'd quit first, because I do NOT have the skills to do so. I could work our post-partum unit with stable moms and simple gyn surgeries, but a specialized unit like L&D? No way.

Second is that we must follow protocols when administering high-risk meds. Insulins, PCAs, heparin drips, epidural infusions, narcotic wastes, etc., should always be double-checked with another nurse. I can't count the number of times I've pulled another nurse aside to witness these things, only to have them sign off or simply nod and walk away without really checking. And then they look at me like I'm nuts when I insist they double check or watch me waste. For anyone that is simply going along and feels they can 'trust' their co-workers to do the right thing, remember that in many cases YOUR name is on the record as double-checking dosages, etc.

I walked in to find a 1500 mg/50 ml morphine PCA programmed as a 1:1 syringe; the patient was receiving 30 times the ordered dose. It had been signed off by 2 staff religiously (as per policy) every shift since it had been started. Thankfully, the patient wasn't harmed (she was used to large doses of po), but had this been placed on one of our post-ops, we'd have had a sentinel event.

Some people just rely on the med scan system because they do not have the time to look back at every medicine that they are giving in the chart to make sure that it is the correct dose or the correct route or the correct etc etc.

We had a pancytopenic post-chemo patient with a platelet count of less than 20 receive a bolus of 25000 units of heparin over an hour because the bag was mislabeled by pharmacy as an antibiotic. I can guarantee you that any nurse who was on staff during that whole fiasco takes the time to double-check scanned meds.

jb2u, ASN, RN

Specializes in ICU, ER, Hemodialysis. Has 5 years experience.

We had a pancytopenic post-chemo patient with a platelet count of less than 20 receive a bolus of 25000 units of heparin over an hour because the bag was mislabeled by pharmacy as an antibiotic. I can guarantee you that any nurse who was on staff during that whole fiasco takes the time to double-check scanned meds.

I understand what you are saying. There is also nursing judgement. Would I just scan a med for say HTN and give it if my pt is 80/50 or give dig without checking a level. My point is "text book" IS the safest, but, sadly, there is not enough time to do everything "text book." That is why staffing is soooo crucial. If we have proper staffing then we can do everything the right way and never try to save time by doing this or that. We focus on med safety, but what about turning q2h or actually taking the time to feed pt's slowly instead of being in such a rush because we know there are a million other things we also have to do. And yes feeding and bathing are important, but so are passing out HTN meds and giving insulin (of course we need to take the time to do the 5 rights!!). That is all I am trying to say. I agree relying solely on what the computer says to give the pt is a dangerous mistake waiting to happen, but so is being so rushed because of short staffing.

i have worked with nurses who will go through the whole mar just looking for a mistake a nurse made so she can report it to the don or if she makes mistake, she will blame it on other nurses and try to get other nurses to get fired. i even worked with nurses who will call a nurse "stupid" because she asked a question and didnt know how to do something. i just dont understand why nurses cannot work together for patients safety and to look after each other. nursing job is hard enough but when the co-workers are stabbing behind your back to get you fired or even your license, i think it makes nursing job so much harder and i dont think its good for the patients. if you find that other nurses are doing something wrong, tell them how to correct the mistake, if a nurses doesnt know how to do something, then demonstrate it so she can do it well next time. i think this will make patient care so much safer.

I interviewed with a NM who took this data to TPTB and managed to get their approval to increase staffing. However, she made it clear that along with this increase in staffing there was an expectation that patients would get turned, fed, etc.

Christie RN2006

Specializes in SICU, EMS, Home Health, School Nursing.

Second is that we must follow protocols when administering high-risk meds. Insulins, PCAs, heparin drips, epidural infusions, narcotic wastes, etc., should always be double-checked with another nurse. I can't count the number of times I've pulled another nurse aside to witness these things, only to have them sign off or simply nod and walk away without really checking. And then they look at me like I'm nuts when I insist they double check or watch me waste. For anyone that is simply going along and feels they can 'trust' their co-workers to do the right thing, remember that in many cases YOUR name is on the record as double-checking dosages, etc.

I do this too! We have scanners where I work, so those help us to catch a lot of errors, but they still are not perfect. The computer system requires us to have another nurse cosign high risk meds such as insulin. One time I had to hang heparin during an emergency situation (my patient was stroking) and the pharmacist was busy in a code (which was in the next room...that was one bad morning!) and was not able to double check my calculations, so I grabbed the nursing supervisor who was on our floor for the code and I made her double check everything with me and chart that she had done that.

Neveranurseagain, RN

Has 26 years experience.

As a RN whose husband died of a "medical incident" (see my previous posts/threads) I feel that what would prevent errors would be hospital/clinics being required to report all near mistakes and all errors and incidents to a no fault reporting system. Until we compile a base to identify how mistakes happen, take real steps to prevent it from happening again and educate the medical staff how these mistakes are occurring, they will continue to happen. The let's sweep them under the rug and not discuss them ensure the error will happen again and again. Staff inservice needs to be held on a regular basis to pass this info of how other medical incidents have occured and how to avoid them. This is one of the many ways error can be prevented. Prevention is the key but it can't be used until the lock is identified.

OC_An Khe

Specializes in Critical Care,Recovery, ED. Has 40 years experience.

In addition to adequate and safe staffing as noted in previous posts there needs to be a cultural change in which errors, that are due to system/ process deficiencies are treated as system error and not looking for some one to sacpe goat and punish. Human beings are not infallaible (neither are bar codes). Punishing some one for an "honest " mistake or system error in the long run is counter productive. Errors are not reported or are covered up and the opportunity to prevent similar errors in the future is lost. Private industry and manufacturing have learned this long ago and have made significant improvements in safety by adopting a culture that doesn't punish these types of errors. Error prevention is the key and this requires openess in order to determine the exact cause(s) of the error. Typically it is a series of mistakes the result in bad outcomes.

Now this, non punishment, does not include errors that result from deliberately by passing safety processes and checks.

purple1953reading

Specializes in ER OB NICU.

I would much rather spend my time taking care of my patients , giving the right meds, expected and ordered cares and treatments, than looking for other people's mistakes. BUT I do check my meds, and in fact , the protocol to prevent med errors is in place for this to happen. The chart check s for 24 hours against the new mars and 24 hours orders help prevent many errors. Those of us who have been in nursing , or worked in small rural hospitals where WE basically are the pharmacist who mixes the meds, know how far we have come with just unit dosing. We used to get a 3 day total dose of a med in bottle, if it were dc'd prior to that time we threw it in the box for pharmacy. This led to much borrowing, if a patient came in that needed the same med, and it would not come from pharmacy for awhile or was not allowed in the "stock"meds that we were allowed to care, Also led to lots of mistakes, patients were charged for the 3 days worth, and then what was used(or just gone) from the bottle was still charged to the patient when returned to the pharmacy. If there were any left, appropriate credits were made. (many times to the wrong patient. All of us develop our own system of checking our meds, to organinzing our days, to prioritizing(within guidelines) and yes I have taken care of 12 patients.In addition, I have learned through the years, just because it is charted or initialed, it is not necessarily done. Like others, I too have seen too many just signe their names, and not really look, whether it be hang blood, checking pcas, etc. Not to be cliche, but the panic diminishes, the mistakes lessen, and your sense of confidence increases, and with this everything starts to fall into place, and although the days are still too short and the duties too long, we become accomplished nurses, who tend to our patients with educated skill, knowledge, and security.

Along with all this comes the ability to recognize when we are in over our heads, and when to compromise to refuse assignments that are beyond our scope of practice, I wil continue to check my meds, wash my hands, and wear gloves. I will continue my detailed notes, keeping up on all that is going on on my pts, and those I supervise. IT is who I am, and the way I see myself as a nurse. I manage 5 kids at home, 3 who are 14, 16 and 17, and find that much more difficult and mentally tiring.

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