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?

Aftermath of the Eric Cropp Sentence: Will the Criminalization of Medication Errors Make Patients Safer in Ohio?

     Although medication errors are not the focus of this blog, I feel it’s important that health care professionals know what is occurring in the state of Ohio, in the aftermath of the Eric Cropp sentencing referenced in this blog’s post Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp  or his Patient (September 5, 2009).

     According to the September 10, 2009 issue of  The Institute for Safe Medication Practices, Legislation has been introduced in Ohio that would establish criminal penalties for pharmacists, pharmacy interns, and qualified pharmacy technicians who fail to report suspected dispensing errors with a “dangerous drug” to the Board of Pharmacy(legislature.state.oh.us%2fbills.cfm%3fID%3d128SB+119)  Criminal penalties would include fines of up to $250 and 30 days imprisonment. Three or more convictions within 6 months would result in increased fines and up to 180 days imprisonment. The Board of Pharmacy would also be required to investigate all errors and pursue disciplinary action if warranted”

The article goes on to say

ISMP adamantly encourages reporting of medication hazards to promote learning. But you can’t punish people for not reporting errors and then subject them to punishment if they do report errors…Ohio pharmacy staff are ” damned if they do” and “damned if they don’t” report errors; in either circumstance, they face the very real threat of imprisonment, fines and a criminal record.”

     Will this type of legislation create a safer environment for patients? Will other states follow suit? Will legislation such as this be applied to health care providers who administer medications, such as nursing instructors training students in clinical rounds, or nurse preceptors? (remember, pharmacist Eric Cropp did not mix the hypertonic chemo, a pharmacy technician did)  Will it drive people away from careers in health care professions? 

Read the full article at http://www.ismp.org/newsletters/acutecare/currentissue.asp 

    

 

Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient

     The Institute for Safe Medication Practices (http://www.ismp.org/) published an article in their August 27, 2009 newsletter, describing a horrific medication error that ended in the death of a child in an Ohio hospital. Just typing that sentence brings tears to my eyes.

     On August 14, 2009, Ohio pharmacist Eric Cropp was sentenced to 6 months in prison, 6 months of home confinement, 3 years of probation, 400 hours of community service, $5,000 fine, and payment of court costs. The Ohio board of pharmacy has permanently revoked his license. He did not mix the chemotherapy.  It was mixed by a pharmacy tech, who inadvertently used 23% saline as the base solution for the infusion that killed the child.

     Documentation from the case further shows that on the day the medication error occurred:

  • The pharmacy computer system was down in the morning, leading to a backlog of physician orders.
  • The pharmacy was short-staffed on the day of the event.
  • Pharmacy workload did not allow for normal work or meal breaks.
  • The pharmacy technician assigned to the IV area was planning her wedding on the day of the event and, thus, highly distracted.
  • A nurse called the pharmacy to request the chemotherapy early, so Eric felt rushed to check the solution so it could be dispensed (although in reality, the chemotherapy was not needed for several hours)

     The article Ohio Government Plays Whack-a-Mole with Pharmacist defends the right of health care professionals and patients to expect safe and consistent systems and policies  from hospitals to prevent the conditions and circumstances creating unsafe work environments, such as the one that has destroyed the life of a child, her family, and pharmacist Eric Cropp. Please read this article.