Advice for Administering Medications with Narrow Safety Margins

I read the order carefully, looked up the medication, and consulted with a pharmacist before giving it. Signing the medication administration record (MAR), I re-read the order. I did not see the same dose I read the first time.

by jparadisi

by jparadisi

Immediately, the blood rushed up from my feet to my ears, and I was lost in pounding waves of white noise. I made a med error! A serious one! I didn’t say these words out loud. Instead, I placed the patient’s chart and the empty, pre-filled syringe in front of the charge nurse. “I think I just made a med error — a bad one. Look at the order and the syringe. What did I do?” She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise subsided into the gentle lapping of my breathing.

Medication errors are potentially heart stopping: figuratively for nurses, verily for patients. ICU  and Oncology nurses have the added stress of routinely administering medications with  narrow safety margins to patients willingly offering their venous access. Further, neonatal and pediatric nurses have patients with less tolerance to any medication or fluid error than their adult counterparts.

While all nurses make medication errors, our goal is to develop strategies to avoid them:

  • Always check chemotherapy or any high risk medication orders beyond the five rights of medication administration. Our oncology services have standardized the double check into a checklist developed from the ONS Safe Handling of Chemotherapy and Biotherapies Handbook. It includes monitoring lab values, confirming appropriate regimen, lifetime dose (if applicable), calculating the correct volume of medication in solution, and more.
  • Don’t rely on memory: Look it up. Pharmacists are also a resource.
  • Consult with more experienced nurses, but don’t rely on their memory either. Look it up.
  • Do not allow interruptions during a medication check. This is not a time for multitasking.
  • Maintain current chemotherapy or other applicable education.

Despite precautions, errors will still occur. Owning and learning from them is the quickest way to move past a bad experience. Supporting a culture of safety in the workplace increases rates of both error reporting and prevention. Colleagues should extend support to one another.

Does your institution have a “culture of safety”? What advice would you add about error prevention? What experiences would you share?

Eric Cropp Talks to ISMP about the Medication Error Leading to a Child’s Death

     The Institute for Safe Medication Practices (ISMP) has published a follow-up article regarding the case of  pharmacist Eric Cropp in the December 3, 2009 issue of Medication Safety Alert! Acute Care, Eric Cropp Weighs in on the Error that Sent Him to Prison. In this article, Eric discribes events contributing to the fatal error.

     Eric Cropp is the Ohio pharmacist who is serving 6 months imprisonment as part of his sentence after conviction for the death of  2 year-old Emily Jerry.  The child died after receiving a dose of chemotherapy mixed in a hypertonic saline solution by a pharmacy technician. My original post on this case, Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or his Patient, discusses the circumstances of this catastrophic medication error.

     For readers following this story, please read Eric’s version of the events leading to the error, which has devastated the lives of the Jerry family, as well as Eric Cropp’s.