ED nurses made 54% of drug errors — You're the 'last safety net' for patients
Very few checks and balances for emergency nurses
A patient is mistakenly given tenectaplase, an investigational drug, due to it being a "look-alike," with proper protocols not followed. Another patient who has cardiac disease is given an inappropriate dose of intravenous metoprolol with a nitroglycerin patch also administrated. For another patient, a tenfold overdose of anagrelide, erythromycin, and proparacain is given, due in part to poor lighting.
All of these patients died as a result of ED medication errors involving nurses, according to a recent study which analyzed 13,932 errors from 496 EDs. ED nurses were responsible for 54% of errors, with most involving incorrect doses or incorrect medications being given — either a medication that wasn't ordered was given, or a medication that was ordered wasn't given.1
Emergency nurses made a larger percentage of errors "only because they are the last safety net on the front lines of medication administration," says Julius Cuong Pham, MD, PhD, the study's lead author and assistant professor of the Department of Emergency Medicine at Johns Hopkins University School of Medicine in Baltimore. "Physicians or pharmacists aren't administering medications. Nurses are the ones administering them, so that is why these errors are falling onto their laps."
Pham says crowding was a factor in many of the drug errors. Two-thirds of 3,562 emergency medicine clinicians surveyed said that nursing staff in their EDs is insufficient to handle patient loads during busy periods, according to a just-published study funded by the Agency for Healthcare Quality and Research.2
"Nurses have a lot of patients they have to take care of, and they are overworked," says Pham. "This burden falls upon our nurses, and we ask a lot of them. In no sense should we interpret this data that nurses are more error-prone than physicians."
As an emergency nurse, years ago, "it used to be that your repertoire was about 10 or 15 drugs, and you just gave them over and over again," says Libby Raetz, RN, director of the ED at Saint Elizabeth Regional Medical Center in Lincoln, NE. "Now we have hundreds of medications, all with different dosages, complications, and interactions. It's just not easy work to keep it all straight. It's very convoluted and complex."
The study sends a message that if any changes are made to improve ED medication safety, they should focus on the emergency nursing role "to help assist nurses to do the enormous job that they are expected to do," says Pham. "As a physician, an error I make gets caught by a pharmacist, a technician, or a nurse. But for nurses, there are very [few] checks and balances."
By using ED nursing protocol order sets, nurses at Saint Elizabeth Regional Medical Center in Lincoln, NE, can start patients on certain medications, such as ibuprofen for pain, with less risk of a dosage error, says Raetz. "We have limited choice. Nurses no longer need to ask, 'Is it morphine or [hydromorphone hydrochloride]? Or, 'What's the dose on that?' We have narrowed the scope so you don't have 100 things to memorize," she says. "The protocols are consistent, so people have learned them."
If patients have a certain complaint and they meet the criteria, a specific medication and dose is given — always. "I think that when you have a lot of variability, that's when you get into trouble," Raetz says.
ED physicians no longer have to enter orders, because the protocol is very explicit for what is given to the patient, she adds.
Another change involved standardizing the dosage of norepinephrine for septic patients. Previously, the ED ordered this in micrograms per minute, while inpatient units delivered the drug in micrograms per kilo per minute. "We had a couple of near misses due to the difference," says Raetz. "We started the patient on micrograms per minute and when we took them up to the floor, they thought it was micrograms per kilo per minute."
To eliminate the potential for this handoff error, a standardized dose now is used of micrograms per kilogram per minute, so no new orders or recalculations are needed.
The strengths of heparin stored in the ED also were limited. "If we need a different strength, we have to call our pharmacy for it," says Raetz.
At Presbyterian Hospital, Charlotte, NC, medications are stocked in "unit dose" containers whenever possible, says Matt Lowery, RN, ED nurse manager. "This means that medications are packaged as close to a usual dose form as possible," says Lowery. "Medications are stocked in the usual appropriate concentration for administration. Any variance from the usual is clearly flagged for the nurse."
References
- Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2008. In press. Doi:10.1016/j.jemermed.2008.02.059.
- The safety of emergency care systems: Results of a national survey of clinicians in 65 U.S. emergency departments. Ann Emerg Med 2008. In press. doi:10.1016/j.annemergmed.2008.10.007.
Take these 6 actions to stop ED drug errors
Here are some practice changes that ED nurses have made to improve safety of medication administration:
1. All intravenous drips are double-checked by nurses.
In addition to double-checking high-risk, low-volume drugs, ED nurses at Saint Elizabeth Regional Medical Center in Lincoln, NE, also double-check the order, rate, and patient for all of the intravenous (IV) drips hung, including insulin, dopamine, nitroglycerine, and mannitol.
"When you give insulin subcutaneously, nursing 101 always is to double-check with another nurse," says Libby Raetz, RN, director of the ED. "We are now double-checking anything we are going to drip for a period of time."
2. Nurses use smart pumps to program dosages.
At Saint Elizabeth, ED nurses are required to program the smart pump before administering intravenous drugs, using the pump's drug library. However, when a compliance audit was done, it was discovered that in some cases nurses were bypassing the pump and setting the rates themselves. "Nurses said, 'We know how to do that,' or 'It takes longer to do it this way.' Some didn't have a reason, they just didn't do it," Raetz says.
The nurses were reminded of the potential for disciplinary action for failing to program a drug into the IV pump prior to administration. "This is hospital policy now. It's not 'Please,' or 'Would you?' It's 'You must.' When you have equipment and safety parameters put in place, you've got to use your tools to ensure patient safety," says Raetz.
3. IV solutions containing medications are separated from general IV solutions.
These IV solutions include mannitol, heparin, dopamine, and nitroglycerin. "We put them in a specially labeled cupboard so there is no confusion. No one can accidentally grab something with meds in it," says Raetz.
4. Verbal orders are no longer used.
"We have virtually eliminated verbal orders in our ED," says Matt Lowery, RN, ED nurse manager at Presbyterian Hospital in Charlotte, NC.
"Any verbal order taken is written, read back, and affirmed with the provider prior to administration in all but the most emergent situations," says Lowery. "Phone orders are minimized and taken using the same protocol."
5. Low-frequency, high-risk medications are reviewed on a regular periodic basis.
"Any new medication introduced to the department is covered by our educators to ensure staff is familiar with the med," says Lowery. These methods are used:
- ED nurses attend periodic inservices on the latest data and indications.
- A unit-based educational team produces computer-based educational modules.
- Staff members are required to attend a "skills fair" on a regular basis, covering medication administration and protocols.
- Lunch and learn sessions are given by medical and pharmacy staff.
6. Nurses are alerted about actual medication errors.
If an ED medication error is reported in the news, the article is posted on a bulletin board for nurses to read, "as well as any other head-turning information related to medication safety," says Raetz. For example, the ED recently posted an article about an incident involving an emergency nurse whose stroke patient died after tenecteplase was administered instead of tissue plasminogen activator.
"Just the article posted on the board has spurred a lot of communication and a big debate in our ED about how the error occurred — whether it was a mix-up of acronyms or a true misunderstanding about which drug should have been given," she explains. "I think it made everyone realize that in a situation like that, they need to be willing to pause and ask the question, 'Is that what you really meant?'"
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