Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN I have been an emergency nurse for more than 20 years and have spent much time precepting newnurses. I have noticed that many novice nurses Reprints not available from the author.
J Emerg Nurs 2004;30:467-9.
make the same medication errors that I myself made when Copyright n 2004 by the Emergency Nurses Association.
I clearly remember how ashamed and inadequate it made me feel to make medication errors, and early inmy career, I became a big fan of nursing journals withmedication error sections where nurses could reportmedication errors anonymously. I always believed that ifsomeone else could make a mistake, then so could I. AsI frequently scanned medication error sections to jotdown errors that were pertinent to ED nursing, I beganto notice a pattern. Often the serious errors that had ahigh potential to harm patients involved the same drugs.
A good example was Epi 1:1,000. For most allergic re-actions, this concentration should only be given subcuta-neously, but often it was mistakenly given by intravenouspush (IVP). This concentration given IVP can causesudden increases in blood pressure, tachycardia, ventric-ular fibrillation, shock, or cerebral hemorrhage. Anothererror that appeared repeatedly in the journals was thatlidocaine IVP was given to a patient in third-degree/complete heart block or a ventricular escape rhythm. Thiscan cause suppression of all ventricular activity resultingin cardiovascular collapse.
Every time I became aware of a warning about a medicaton error, I would add it to a small handwrittenpocket guide that I was assembling for the new nurses Iwas orienting. In 1996, our emergency department’seducation committee decided to publish the guide, andit evolved into our current ED Orientation Survival C L I N I C A L N O T E B O O K /A n o n y m o u s Guide. The pocket-sized guide includes many high-risk Recently, I had an experience that was a perfect drugs such as insulin, heparin, labetalol, 1:1,000 Epi and example of the benefits of a culture of sharing information t-PA and what the common errors are. It is still very popular, about medication errors. After returning to work following even with many of our experienced nurses.
a lengthy absence, I discovered that the pharmacy could no Several years later, our ED nurse representative to the longer obtain Solu-Medrol. There was a note on our hospital-wide committee that discusses medication errors automated medication dispenser, Pyxis, to substitute and how we can prevent them (our hospital is proactive 20 mg of Decadron for 125 mg of Solu-Medrol. Although about errors in this and many other ways) left, and I I should certainly have known better, I asked one of our volunteered to take her place. I was introduced to the nurses if it was okay to give it the same way—that is, IVP.
Institute for Safe Medicine Practice’s (ISMP) bnon- She answered yes, so I proceeded to give the Decadron punitive system-based approach to error reduction.Q They IVP. My first patient had no problem. The second patient advocate providing incentives for reporting errors without I gave the drug to complained of severe burning in the genital area. I immediately researched the drug and dis-covered the maximum amount of Decadron that can be given IVP is 10 mg. Thankfully, my patient suffered no permanent harm. Perhaps emboldened by the fact that Iwas on the Medication Error Quality Improvement Committee, I told other nurses how badly I felt about t-PA and what the common errors are.
the discomfort and worry that I caused my patient. Themore nurses I talked with, the more I realized that many of This concept was totally new to me. A new medication my colleagues were doing the same thing. Some of their error reporting form was developed by our hospital that patients had also complained of burning in the genital did not require a signature so errors could be reported area. I decided to post a flyer on the Pyxis to alert staff that anonymously. In addition, at each monthly meeting, we 20 mg of Decadron should be diluted and given intra- began reviewing the errors published in the ISMP’s venous piggyback. After the flyer went up, I had several Medication Safety Alert bulletin.* With each error, we more nurses tell me that they had had the same thing asked, bCould this error happen in our hospital?Q We found that many of those tips were invaluable.
I began to encourage other ED nurses to take the time to document medication errors. I put up flyers with messages like, bThank you for taking the time to reportyour med errors. The safest hospitals are the ones with the highest reporting rates.Q I must admit that at first the f lyer got a few laughs, until I explained what it meant. It took a while, but our nursing staff slowly became morecomfortable and less fearful about reporting mistakes. Our reporting rates began to increase. Our nurse manager, unit educator, and I began to meet to discuss and analyze errors colleagues were doing the same thing.
to find contributing factors. We talked about what changeswe could make to prevent more errors.
Several months later, I was surprised when one of our best and most experienced nurses said to me, bI havelearned something valuable from you. Now, when I make a *The ISMP Medication Safety Alert bulletin can be obtained at med error, I tell everyone.Q It was as though a light bulb [email protected] or telephone 215-947-7797 for $140 per year(25 issues). It comes by E-mail and can be distributed within the hospital.
went off in my head!! We had used the same principal as C L I N I C A L N O T E B O O K /A n o n y m o u s ISMP, just on a smaller scale. This was real progress!! also should leave the settings on the pump just as they When I talked with my sister (also a registered nurse on the were so that Bio-med could actually trace what had night shift in our emergency department) about this malfunctioned. Leaving the settings the same was new concept, she said that whenever she hears anyone talking information for every nurse in the meeting, and there were about a medication error, she always perks up and listens.
many very experienced nurses there. So, once again, the I now add errors that are reported in the ISMP to All in all, the nurses at the meeting were very receptive my Orientation Survival Guide on a regular basis. For to the idea, and even a non-nursing staff member came up example, the ISMP bulletin reported that after Lovenox is to me after the meeting and said, bI really like your idea of given subcutaneously, you need to wait 12 hours before sharing errors.Q While I would like to think that nurses starting heparin. In several other hospitals, neglecting to have been doing this for years and I just have not noticed, I do this had caused intracranial bleeds. I included the fact do not think that is true. Often, it seems, the simplest that you need to give the new rapid-acting insulins, concepts may improve the care of patients the most.
Humalog and Novalog, right with the meal. For yearswe had given insulin 30 minutes prior to the meal, so thiswas a big change.
Send descriptions of procedures in emergency care and/or quick- I do not believe the concept of sharing errors has to reference charts suitable for placing in a reference file or notebook to: be limited to medication errors. Our emergency depart- ment recently purchased a new pediatric crash cart. I c/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002 was in triage one morning and a mother walked in 800 900-9659, ext 4044 . [email protected] with a 2-week-old baby who was having difficultybreathing. After one look at the baby, I immediatelytook the mother and baby back to the main emergencydepartment. Although there had been an orientation tothe new cart in a Skill Update several months before, Icould not find the handle to the laryngoscope. It turnsout it was now in the bottom drawer, rather than the topdrawer, where it had always been. In the end, we justventilated the baby with the ambu bag a little longer andthe baby was fine. However, I made a point of tellingeveryone. I believed that if I could not find it, then othernurses might not be able to find it either.
At the last ED staff meeting, when I gave my monthly report on medication errors, I decided to share this ideawith our nurses. The feedback was great. Another ex-perienced nurse began to share her own recent medicationerror. She had set the rate on the infusion pump at 20 mLper hour and went back in to discover the rate was 200 mLper hour. Being on the medication error committee, Imentioned that it was entirely possible she had set the ratecorrectly and the pump had malfunctioned. Our nursemanager advised us that if this occurred, besides taking thepump out of service, labeling it, and calling Bio-med, we


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