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How Nurses Can Avoid the Medical Error Nightmare

BY SUE MONTGOMERY, RN, BSN, CHPN

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Medical errors are a nurse’s worst nightmare. Most of us are familiar with the knee-buckling, blood-draining panic that sweeps through you when you realize you’ve made a mistake, whether it’s the wrong med, the wrong patient or the wrong dose. The possibilities for error are endless and each time you start a shift, you know they could happen to you. 

Of course, you learned best practices in nursing school, but the rapid changes in medication, technology and procedures would test even the most conscientious clinician’s sanity. A little extra caution could save your career and maybe even a patient’s life.  ‘

A COSTLY PROBLEM

Medical errors are a persistent blight on America’s healthcare system. An article in the September 2013 edition of the Journal of Patient Safety reported jaw-dropping figures: Each year, between 210,000 and 440,000 hospitalized patients die because of preventable adverse events (PAEs). Some of those deaths are close to home. The Department of Public Health recently fined 13 California hospitals a total of $14.1 million for mistakes that allegedly resulted in five patient deaths, one case of severe neurological damage, an unexpected code and a retained surgical sponge. 

Who pays for these medical errors? We all do, of course. For healthcare providers, the cost is measured in fines, punitive court judgments and legal fees. For patients and families, the cost is too often disability or death. As nurses, we pay with our hearts. We’re naturally concerned about legal consequences and the risk of punishment, but we care deeply about our patients and the perceived betrayal of trust when we make an error, which leaves us not only afraid but ashamed.

Unfortunately, nurses typically make more errors than any other category of healthcare provider. We’re the shortstops of healthcare: We see the most action and we drop the most balls. The good news is that it doesn’t have to be that way if you stay on top of your game.

AVOIDING MEDICATION MISTAKES

A complete list of every possible type of medical error would fill many books. Some mistakes are the result of serious institutional problems like poorly designed or bug-ridden electronic medical records systems. Others — including many of the most common PAEs involving nurses — are individual mistakes that can be avoided with proper diligence. 

Unsurprisingly, many common errors involve medication. If you can’t recite the Institute for Healthcare Improvement’s Five Rights (right patient, right drug, right dose, right route, right time), you probably shouldn’t be practicing at all, much less passing meds, but it’s scary how often nurses miss at least one of those five.

Here are some tips to help keep us all on the right path:

Beware of look-alikes. New medications appear almost every day and many of those meds have names that look or sound too similar for comfort. Make sure you’re familiar with the latest Institute for Safe Medication Practice (ISMP) list of confused drug names, which includes look-alike and sound-alike drugs that have been involved in medication errors. Wherever possible, store look-alike medications in different areas and group drugs by category rather than alphabetically.

Watch for high-alert meds. The ISMP also issues lists of high-alert medications “that bear a heightened risk of causing significant patient harm when they are used in error.” Based on error reports from a variety of sources, the list is designed to warn healthcare providers of medications that may require special handling to reduce the risk of serious errors. Check out the link and make sure that high-alert and other dangerous medications such as neuromuscular blocking agents and concentrated potassium chloride are stored separately from commonly used, less-risky supplies.

Sterile doesn’t mean safe. There are many alarming stories about patients who were administered wrong solutions via wrong routes because containers on sterile fields were left unlabeled. In one particularly terrifying incident, a Seattle patient died because she was accidentally injected with cleaning solution. Label everything and don’t assume you know what’s in a bulb syringe, medication cup or other container just because it’s in the sterile field.

Oh, that tricky tubing. Back in April 2006, The Joint Commission issued a Sentinel Event Alert about tubing misconnections, which are a common cause of medication errors. There are various safety recommendations, but the most important are:

Trace it back. Always trace every line back to its origin before connecting or disconnecting anything.

Turn on the lights. That patient you’re trying to tip-toe around would rather deal with the glare than the result of your attaching the wrong solution to the wrong line.

Please don’t touch. Remind patients and families that they should never reconnect lines themselves.

Label all tubes and catheters. This is particularly critical for high-risk tubing like epidural, intrathecal and arterial catheters.

 

BUILDING A SAFETY NET

There are a number of simple strategies you can follow to reduce your risk of common errors. Here are just a few:

• Quiet, please. Perform critical tasks in distraction-free zones whenever possible. 

• Slow down. It’s always better to take an extra moment to be sure of what you’re doing.

• Communicate better. Keep critical communications complete, concise and to the point, following the SBAR (situation, background, assessment, recommendation) model. (Click here for this communications strategy.)

• Don’t cheat. Taking shortcuts with established safety procedures can lead to disaster. 

• Learn to love technology. Especially if you’ve been practicing for a long time, new technology and new systems may seem like a pain, but they can enhance patient safety.

• Empower patients. Involve patients in what you’re doing and encourage them to speak up if they have questions.

• Educate yourself. Additional safety information can be found in resources like the Agency for Healthcare Research and Quality’s voluminous Patient Safety and Quality: An Evidence-Based Handbook for Nurses  and the website of the National Patient Safety Foundation. Take advantage of them.

WHEN MISTAKES HAPPEN

Everyone makes mistakes, and when you do, it may be very tempting to keep it to yourself. While the American Nurses Association recommends a “Just Culture” approach that focuses on correcting and avoiding mistakes rather than punishing people for them, not all organizations follow that model — and the penalties can be severe. 

However, not reporting an error is likely to compound the harm to the patient, possibly with lethal consequences. Furthermore, if your hospital does take a punitive attitude toward mistakes, things will go even worse for you if you weren’t the first to speak up. It’s always better to put the safety and well-being of your patient first.

PAINFUL DETAILS, LASTING SOLUTIONS

If you’re involved in a medical error, even if it wasn’t your fault, don’t be surprised if you’re asked to help figure out what happened. In the case of a “sentinel event” (an incident that results in death, injury or the risk of death or injury), the Joint Commission requires healthcare facilities to use a process called root cause analysis. This involves a standardized list of 24 questions to determine what factors were involved in the event with an eye toward preventing future incidents (although institutions sometimes use the same process for other purposes). 

Sometimes, healthcare organizations also use what’s called failure mode effects and criticality analysis (FMECA), which involves looking for potential weak spots in the organization’s procedures. FMECA isn’t exclusive to healthcare — it’s also used in industries like aerospace to identify possible failure points so that corrective measures can be taken. FMECA is usually a more proactive process while root cause analysis is usually used after an incident. 

Either process can be painful and frustrating for the nursing staff, involving a lot of intrusive and time-consuming questions about minor procedural details. However, this type of analysis is very useful for getting to the bottom of medical errors and reducing the chances of their happening again, both at your hospital and others like it.

FACING THE RISKS

Whether you’ve been a nurse for one day or 40 years, the risk of making an error is something you face every time you clip on your badge. Some of that is just the nature of our profession: Nursing is important work that demands a high level of skill in a fast-moving, stressful environment. However, by following these tips and taking extra care with everything you do, you can reduce the odds of putting your patients or yourself in harm’s way.

Sue Montgomery, RN, BSN, CHPN, is a critical care and hospice nurse who writes on healthcare issues. She is a member of the Hospice and Palliative Nurses Association and American Medical Writers Association.

Source: Working nurse