Articles: Medical Errors
Preventing Medication Errors
(originally
appeared at www.NursingSpectrum.com)
The
neonatal nurse was thinking about her dinner break when
she removed the intravenous lipid tubing from the IV pump.
It was attached to the infant’s intravenous site with
a stopcock. Convinced she had closed the stopcock, she left
the bedside with 200 mL of lipids hanging in a glass bottle
above the infant’s head. Two and a half hours later,
she noticed that the infant’s abdomen was getting
distended. She notified the physician, who ordered blood
work. When the lab technician inserted a needle into the
infant’s vein, a milky white solution entered the
tube. Nearly 180 mL had infused into the neonate. The nurse
documented the incident in the nurses’ notes but didn’t
record the amount of lipids that freely flowed into the
infant. A frantic Internet search by the neonatologist showed
that there was no known way to counter such a massive overdose
of lipids. The infant suffered profound brain damage and
developed quadriparesis and blindness as a result of the
overdose. The case against the nurse was settled out of
court for a seven-figure award.
Medication
errors can occur in a fraction of a minute and can go undetected
for hours, as this case illustrates. There are multiple
opportunities to make medication errors in our complex medication
ordering, dispensing, and administration systems. Misinterpretation
of a handwritten order, failing to recognize and question
an incorrect order, or not carrying out the medication administration
steps properly can result in an error.
While
there are many causes of medication errors, the two main
ones reported to the US Pharmacopeia, a voluntary medication
error reporting system, were “performance deficit”
and “failure to follow a procedure or protocol.”
Contributing factors for performance deficit errors were
distractions and workload increases, while contributing
factors for failure to follow a procedure or protocol were
distractions and staff inexperience. This free-flow medication
error was caused by distraction and failure to follow the
safety procedure of closing the tubing flowmeter, closing
the stopcock, and keeping the tubing connected to the pump.
The Joint Commission on Accreditation of Healthcare Organizations
has recommended that hospitals purchase IV pumps that will
not permit free flow of intravenous solutions and medications.
There
are several steps that you can take to reduce the risk of
medication errors:
- Never
hesitate to obtain up-to-date information about the medications
you’re expected to administer.
- Keep
sources of drug information at hand and consult them often.
- Never
hesitate to question an order that looks incorrect.
The
nurse acts as the patient’s voice to question inappropriate
orders. Don’t allow angry or intimidating behavior
to deter you from expressing your concerns about an order
that’s incorrect. Abusive physician behavior occurs
less often these days as it becomes more obvious that these
interactions are unacceptable, drive nurses out of jobs,
and increase the risk of patient harm by deterring questioning.
Teach
your patients about the medications they’re receiving.
Listen to patients who question a medication. Statements
like “I’ve never seen that type of pill before”
or “I usually get this medication every four hours”
should never be ignored. Keep your eyes and ears open. If
you see an unsafe medication practice occurring, report
it. The “near misses” help us identify flaws
in the system. Who better to see the danger in the system
than a nurse who gives medications on a daily basis? It’s
devastating to the defense of a hospital in a lawsuit when
its nurses recognized a dangerous situation but failed to
report it or, worse, were ignored when they did.
Don’t
take shortcuts when giving medications. Each step
in the medication administration procedure is designed to
promote safety. Checking the patient’s armband, labeling
a syringe, reviewing a medication administration record
before giving a drug, signing for each dose of medication
you give, and having someone double check your calculations
when giving high-risk medications are all important safeguards.
As an expert witness, I’ve seen medication errors
result from omitting any one of these steps.
If
you make an error, never cover it up. Ensure that
the patient is evaluated by a physician and that the incident
is reported in the medical record, as well as on an incident
report. This documentation helps establish the facts of
the case when the information is fresh in everyone’s
mind. Failure to report an incident may be construed as
a coverup and worsens the penalties within the legal system.
Deliberate omission of documentation about an incident is
considered tampering with the medical record. It may place
the employer at risk for punitive damages at a trial —
damages that aren’t covered by insurance. A Pennsylvania
LPN is in prison for tampering with the medical record after
failing to transcribe a medication order.
She was prosecuted under the federal Health Insurance Portability
and Accountability Act, which precludes making “false
statements” in a case involving a federal healthcare
benefit program.1
A suit
against a nurse for a medication error must establish four
points: The nurse had a duty to provide care to the patient;
the nurse didn’t follow the standard of care; the
patient was harmed; and failure to follow the standard of
care was the direct cause of the patient’s injury.
There are many medication errors that don’t result
in harm; tragically, though, a small number cause permanent
injury.
Legal
nurse consultants serve as liaisons between the medical
and legal disciplines, offering support in medically related
litigation and other medical-legal matters. Among other
things, they review medical records and help attorneys recognize
cases with merit. The American Association of Legal Nurse
Consultants (AALNC) is the professional nursing organization
that represents nurses in this specialty area. For more
information about AALNC and the expertise that nurses can
provide in the legal arena, the the group’s website,
www.aalnc.org.
As a
legal nurse consultant, I helped the infant’s mother’s
attorney understand each of the deviations from the standard
of care committed by the neonatal nurse in the lipid overdose
case. I also prepared the attorney for the depositions of
the nurse and other staff in the neonatal unit at the time.
When the defense attorney’s physician expert attempted
to blame the infant’s prematurity for the brain damage,
I supplied the attorney with literature about lipid overdoses,
and a timeline was prepared that showed the infant was developing
normally before the overdose. This information helped the
attorney understand the medical issues and was instrumental
in settling the case out of court.
This
case is a good example of the important roles that nurses
can play in reducing medication errors.
Patricia
Iyer, RN, MSN, LNCC, CLNI is president of the American Association
of Legal Nurse Consultants and is the editor of the second
edition of Legal Nurse Consulting, Principles and Practice
and Nursing Malpractice. She reviews cases as an expert
witness.
References
1. Miller R. Former nurse to serve time for falsifying
patient’s chart. Express Times. November 2001. (back)
Bibliography
Summary of the 1999 Information Submitted to
MedMARx. Rockville, MD: US Pharmacopeia, 2000.
Med
League locates nursing
and physician
experts, retrieves articles supporting the standard
of care, prepares timelines, chronologies,
& other exhibits.
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