Posts Tagged ‘medication errors’


Too Tired to Nurse

December 8, 2014

By Shawn Kennedy, AJN editor-in-chief

by patchy patch, via flickr

by patchy patch, via flickr

Just about every nurse I know has been “asked” (or “guilted” or “mandated”) to work an additional shift on top of a grueling one. The worst such experience I ever had was having to work from midnight to 8 am after working a straight week of 4 pm to midnight shifts. I was exhausted, but someone had called in sick, leaving only two RNs and one aide for the 11-bed ED trauma unit.

I was so tired that at one point I found myself falling asleep while I was standing by a patient’s bed charting vital signs. I couldn’t remember the blood pressure reading I had obtained just moments before. It was good luck that I didn’t make an error—and had the good sense to have a colleague double-check medications I was readying (these were the old days, before unit dosing). Read the rest of this entry ?


AJN’s February Issue: New Nurses, Children’s Posttonsillectomy Pain, Medication Errors, More

January 31, 2014


AJN’s February issue is now available on our Web site. Here’s a selection of what not to miss, including two continuing education (CE) articles, which you can access for free.

With high hospital turnover rates, keeping newly licensed RNs (NLRNs) continues to be a priority for hospitals. This month’s original research article, “Changing Trends in Newly Licensed RNs,” found that new nurses considered themselves to have fewer job opportunities and to be less likely to work in hospitals and more likely to have a second job than new nurses who were surveyed six years earlier. Earn 2.5 CE credits by reading this article and taking the test that follows.

Tonsillectomy is effective at treating a variety of pediatric disorders, such as sleep apnea and frequent throat infection. But it often results in prolonged, moderate-to-severe pain. “Posttonsillectomy Pain in Children” reviews the causes of posttonsillectomy pain, the efficacy of various treatment interventions, and the recommendations for patient and family teaching regarding pain management. Earn 2.3 CE credits by reading this article and taking the test that follows. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by tapping on the podcast icon on the first page. The podcast is also available on our Web site.

According to an Institute of Medicine report, at least 1.5 million preventable medication-related adverse events occur in the U.S every year. This month’s Cultivating Quality article, “The Sterile Cockpit: An Effective Approach to Reducing Medication Errors” (abstract only without a subscription or article purchase), describes how nurses on one hospital unit used a commercial aviation industry innovation in an attempt to reduce medication errors. Read the rest of this entry ?


Health Technology Hazards: ECRI’s Top 10 for 2013

January 4, 2013
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

It’s a new year and with it comes new health care technology hazards to keep in mind, as listed in the most recent ECRI Institute report, 2013 Top 10 Heath Technology Hazards. While some risks from last year’s list made a repeat appearance, a few new topics made the cut for 2013.

Alarm hazards still posed the greatest risk, topping the list at number one. Other repeat hazards included medication administration errors while using smart pumps, unnecessary radiation exposure, and surgical fires. For an overview on these, see our post from last year.

Several new opportunities for harm seemed to involve new information technology (IT) that is making its way into health care facilities, such as smartphones and mobile devices. Here’s a snapshot of several of these, and some suggestions the report gives on how to prevent them.

Patient/data mismatches in electronic health records (EHRs) and other health IT systems

The risk:
One patient’s records ending up in another patient’s file may not be a new phenomenon—it happened in traditional paper-based systems as well. But newer, more powerful health IT systems have the capability to transmit mistaken data to a variety of devices and systems, multiplying the adverse effects that could result from these errors.

Some suggestions: The report suggests that when purchasing health IT systems, facilities should consider how all the connected technologies facilitate placing the right patient data into the right record. It also states that a “patient-centric” approach is preferable to a “location-centric” one. All patient flow and device movement should be kept in mind, as well as planning for all types of transfers (not just routine ones). And during implementation of any project or software upgrade, appropriate testing should be carried out to avoid surprises.

Interoperability failures with medical devices and health IT systems

The risk:
Establishing interfaces among medical devices and IT systems has the potential to reduce errors associated with manual documentation, but achieving the appropriate exchange of data can be difficult, and can lead to patient harm. (For example, interfaces between medical devices may not work properly, systems can be incompatible, and one device can have unintended effects on another.)

Some suggestions: Although there are challenges to integrating medical devices and systems, the report stresses that health care facilities should be actively engaged in the process—albeit cautiously. An inventory of interfaced devices and systems, including software versions, should be kept. Hospitals should follow best practices as described in the International Electrotechnical Commissioner’s standards (available on the International Organization for Standardization’s Web site). When making changes to interfaced equipment, all stakeholders should be involved (and this includes nurses). Finally, before any broad system modifications are implemented, testing should be carried out to ensure everything works as expected.

Caregiver distractions from smartphones and other mobile devices

The risk: While much has been said about the security considerations associated with the use of smartphones, tablet computers, and other handheld devices, another topic that is starting to get attention is the potential for substandard patient care or even physical harm to patients if caregivers are distracted by their devices. Making mistakes or missing information as a result of distraction isn’t the only problem. Caregivers who are distracted by their devices may miss clues about the patient’s condition or cause patients to question the quality of their care.

Some suggestions: According to the report, staff should be educated about the risks associated with the use of smartphones and mobile devices, especially the potential for digital distractions that affect patient care. Hospitals should come up with a “mobile device management strategy” that includes appropriate use of the devices, including specific measures users must take to ensure safety and security. Hospitals may also want to consider restricting personal use of these devices during patient care activities.

Other hazards that topped the list for 2013 include the following:

  • air embolism hazards
  • inattention to the needs of pediatric patients when using technologies that may have been  designed for use in adults (such as radiology, oxygen concentrators, computerized provider order-entry systems, and electronic medical records)
  • inadequate reprocessing of endoscopic devices and surgical instruments

Click here to request a copy of the full report.—Amy M. Collins, editor

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That Acute Attention to Detail, Bordering on Wariness…

November 21, 2011

via Wikimedia Commons

By Kinsey Morgan, RN. Kinsey is a new nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA. Her last (and first) post at this blog can be found here.

It seems that nursing schools across the world subscribe to certain mantras regarding the correct way to do things. Different schools teach the same things with utmost urgency. Hand washing is one of the never-ending lessons that comes to mind. How many times do nursing students wash their hands while demonstrating the correct way to perform a procedure? I vividly remember actually having to be evaluated on the skill of hand washing itself.

Another of the regularly emphasized points of nursing school is double-checking. One of my first clinical courses required students to triple-check patient identification before giving medications. We were to look at the medication administration record, the patient’s wristband, and then actually have the patient state their name.

As a new nurse learning several new computer systems for charting, etc., I’ve noticed that the old attention to detail, ground into my soul during my school days, now seems easy to overlook, since computers do so much of the work. Of course, computer charting and electronic MARs* have simplified tasks and made time management much less daunting. But sometimes I worry about the hidden cost of such improvements.

I intend, vow, resolve to make an effort to remain aware of how easily errors can happen when we don’t double- and triple-check things. I want to always retain that astute attention to detail, bordering on wariness, so that I can practice as safely as possible, even with the advent of electronic methods.

*MARS = medication administration records

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Memorial Day Weekend Notes from the Nursosphere Blog Roundup

May 27, 2011

As I walked into the exam room and introduced myself as a nurse practitioner, the patient announced she was “forced” to come to our clinic and “wasn’t allowed to see a real doctor” downtown. I was slightly taken aback. Here I was, running on time, in a pretty good mood and ready to assess and treat to the best of my abilities, and then WHAM. I took a deep breath and realized she wasn’t slamming NPs; she had a grudge against military providers, regardless of education background.

That’s from a recent post by a U.S. Air Force family nurse practitioner (NP) who’s been blogging from Afghanistan. She’s home now, and the post, about being discriminated against by a patient—not because she’s an NP, but because she’s a military provider—is worth noting as we prepare for another Memorial Day Weekend.

Memorial Day Flags/Eddie Coyote, via Flickr

Are you a nursing student, or just ready for a change in your nursing career? Curious about various nursing specialties and what they really involve? Codeblog has been running a helpful series of posts, each of which focuses on an interview with a particular type of nurse. The latest is with a cardiac catheterization lab nurse.

Nothing like a medication error to ruin everyone’s day. Lisa at In the Round has a useful post that lists the eight “rights” of medication administration.

“So there is very little, in the end, I won’t share. There are some things, however, that are beyond the pale. Here’s my short list of ten things I will never, ever tell you, my patient.” That’s from a recent post at Those Emergency Blues: “Don’t Tell Your Patient This. Or That.” Have a look and see if you agree.

Lastly, an article today on the NY Times “Well” blog summarizes the findings of a new report on the activity levels of Americans in the workplace. The basic idea is that we’re less active at work, and since we spend much of our time and energy at work, we’re also increasingly obese. Many nurses might dispute this finding if they spend their days on their feet. But it’s worth considering, as many of us prepare for a long holiday weekend full of opportunities to eat, relax, and also, yes, to get a bit of exercise—even if it’s only a matter of taking a daily walk after dinner in the lingering late May light. Or, as Sean at My Strong Medicine puts it, a little bluntly: “What Was Your Excuse for Not Exercising?” 

Point taken.—JM, senior editor

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Checklist, Please!

June 28, 2010

Christine Moffa, MS, RN, AJN clinical editor

It’s embarrassing to admit how many times I’ve either locked myself out of my apartment or arrived at work and realized I’d left either my wallet or cell phone at home. That is, until someone very close to me taught me to say, “wallet, keys, cell phone, Metrocard” before walking out the door. Little did he know he was using a very powerful tool, the checklist.

As part of my money-saving strategies this year, I’ve resorted to using the New York Public Library to support my reading habit, instead of going to the various megabookstores in my neighborhood (I always fall for the “buy-two-get-one-free” deal!). That’s why I’m late to the party for The Checklist Manifesto, by Atul Gawande. After three months on hold, my turn finally came up—and boy was it worth the wait. There are so many great anecdotes about success stories (and some failures) of checklists—including patients surviving accidents and surgeries against all odds, averted airplane crashes, and well-orchestrated rock concerts—that it makes me want to start implementing checklists in every aspect of my life (including some at AJN). In fact, if I’d had a checklist for packing my bag for this weekend, I’d have remembered my flat iron, amongst other necessities. Now I’m forced to go the next 48 hours with serious frizz! 

My favorite part of the book, though, is that Gawande gives credit to nurses for being the originators of checklist usage in hospitals, citing vital sign charts, medication administration records (MARs), and care plans.

Checklists, it turns out, foster communication, which in turn leads to teamwork. Who knew? In this world of ever increasing complexity, there are so many details to focus on it’s easy for errors to happen. Often you have to focus on your own responsibilities and trust that your colleagues are taking care of theirs. The checklist brings us all back to the same page; if nobody can proceed until it’s confirmed that a particular task has been performed, we’re forced to check in with each other.

If you’d like to make a checklist of your own, you can visit Gawande’s  Web site and download a “Checklist for Checklists,” or see some examples of those used in the medical and aviation industries.

Do you have a favorite checklist that you find helpful either in your personal or professional life? Let us know about it.

Atul Gawande's "Checklist for Checklists"

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In Medicine as in Aviation, Communication Breakdown Leads to Fatal Errors

January 19, 2010

by dobrych, via Flickr

By Christine Moffa, MS, RN, AJN clinical editor

Lately I’ve had communication on my brain. I’m always amazed that we get anything done in this world at the rate that messages can get lost in translation. For instance, I recently had a phone call from a mother of two girls who was upset about a medication error involving her 12-year-old daughter. While the mother was at work, the child came home from school with cold symptoms and a temperature of 102.5. The daughter called her mother and was told to take two tablets of Sudafed, which she did. About an hour later, the babysitter picked up the younger child, age nine, from school. Concerned that her sister was sleeping unusually soundly, the nine-year-old called her mother at work. Realizing that just giving her older daughter Sudafed hadn’t addressed her fever, she told her younger daughter to wake up her sister and have her take “two Advils.” 

A few hours later the mother came home from work. As she was about to give her daughter another dose of medication before bedtime, she remarked to the children that she wished she had a combination drug containing both Sudafed and Advil so that the girl wouldn’t have to swallow four separate pills. The nin- year-old informed her that they did in fact have Advil Cold and Sinus; in fact, that was what she had given her older sister earlier when her mother told her to give her two Advils. The mother realized that her 12-year-old had ended up getting 120 mg of pseudoephedrine within one hour. Fortunately, her daughter was fine—before she called me, she had already called her doctor as well as poison control—but it did cause a scare for her family.

What went wrong?

  1. No adult was in the loop; at no point did the babysitter and mother speak about the plan for the child.
  2. The use of a brand name to refer to a drug instead of its generic name: the family had a bottle of generic ibuprofen in the house, but the mother used the word Advil.
  3. The person taking the medication was handed two pills without seeing the package that they came from.

It so happens that when I got the call I was reading a great book by Malcolm Gladwell called Outliers. According to the author, “A lot of the book is an attempt to describe the lives of successful people, but to tell their stories in a different way than we’re used to.” Read the rest of this entry ?


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