Medication Safety – Part 2

Sandy Beauman, MSN, RNC-NIC

Every nurse has a healthy concern for making a medication error.  There have been stories in the news of cases where medication errors have led to severe consequences and even death in the neonate.  Often, the nurse is affected as well.

We become nurses to care for patients and feel very protective of the tiny infants in our care.  To think that something we did or didn’t do has led to a poor outcome is devastating.  I witnessed a medication error in which a bolus of potassium was given instead of Calcium Gluconate.  The patient arrested but was resuscitated and survived.  The nurse was devastated though, and ultimately left neonatal nursing.  There are several stories of heparin overdose in the literature that has led to changes in how we use heparin and an evaluation of whether heparin is really needed in situations where we have used it in the past.  In many, if not all of these cases, there was something in the system that allowed the error or perhaps even made it easier to make the error than to avoid it.

This brings us to the topic of medication error “near misses”.  These are situations where you, at the bedside, see the potential for an error but it has been averted.  The importance of these near miss events cannot be underestimated.  Often, we breathe a sigh of relief that the error was avoided but it presents an opportunity to evaluate the system and why the error made it as far as it did.  We put double and triple checks in place to avoid just this.  For instance, the physician or nurse practitioner writes an order for a medication that is incorrect.  The pharmacist must then check the order before dispensing, providing another check.  If the pharmacist does not catch the error, the nurse then receives the medication erroneously and is to check the medication.  This provides a triple check.  Many units have also required a check between two nurses before administration, creating a quadruple check of the medication.  However, these checks are only as good as the people checking it.  We all learned the 5 rights of medication administration.  These should all be checked by the nurse who double checks the medication as well as the nurse administering it.  Many reported errors have occurred because the nurse administering the medication simply tells the other nurse what the medication is and how much the dose is.  This creates what is referred to as a preconception bias.  If this information is given to the second nurse, she or he then “sees” this in the syringe and is unable to ignore this bias.

These five rights of medication administration are:

·       Right patient

·       Right medication

·       Right dose

·       Right time

·       Right route

In recent years, some have expanded this list to include:

·       Right indication

·       Right expiration (not an expired med)

·       Right dilution/concentration

The true independent double check requires that the second nurse read the medication, dose and time from the patient’s medication administration record and independently validate the patient’s identification.

Back to the “near misses”. ….These are opportunities for improvement without an error having reached the patient.  What better opportunity to make improvements!  Here are some examples of near miss scenarios and possible improvements.  While it is important to evaluate every opportunity for improvement, it is also important to remember that the improvement must also be evaluated completely in each setting as it may create opportunities for other errors!  Below are some common areas where errors occur and suggestions for improvement in these areas.

Medications that were dispensed incorrectly due to transcription errors:

·       Computer based physician order entry

·       Handwriting improvement – yes, some hospitals have required handwriting classes for physicians!

·       Scanning or faxing original orders only

Medications diluted incorrectly

·       Move medication dilution from the nursing unit to the pharmacy

·       Require double checks in the pharmacy before dispensing

·       Use of standard dilutions

·       Use of standard concentrations available from manufacturer, wherever possible

Orders written incorrectly

·       Pre-printed dosing guidelines (such as for Digoxin)

·       Order sets including dosing parameters

·       Availability of neonatal medication references to double-check doses

About the Author

Sandy Sundquist Beauman has over 30 years of experience in neonatal nursing. In addition to her clinical work, she is very active in the National Association of Neonatal Nurses, has authored or edited several journal articles and book chapters, and speaks nationally on a variety of neonatal topics. She currently works in a research capacity to improve health care for neonates. Sandy is also a clinical consultant with Medela. You can find more information about Sandy and her work and interests at