Preventing Medication Errors

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. Such errors have also led to some patients abusing medications and becoming hooked on them in the process.

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 the 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.

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 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.

References
1. Miller R. Former nurse to serve time for falsifying patient’s chart. Express-Times. November 2001.

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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