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Error-prone conditions that lead to student nurse-related errors

From the October 18, 2007 issue

If your organization provides a site for clinical rotations of student nurses, you are probably aware that students can be involved in medication errors despite close supervision by their clinical instructors. When analyzing errors involving student nurses reported to the USP-ISMP Medication Errors Reporting Program and the PA Patient Safety Reporting System, it appears that many of the errors arise from a distinct set of error-prone conditions or medications. Some student-related errors are similar in origin to those that seasoned licensed healthcare professionals make, such as misinterpreting an abbreviation, misidentifying drugs due to look-alike labels and packages, misprogramming a pump due to a pump design flaw, or simply making a mental slip when distracted. Other errors stem from system problems and practice issues that are rather unique to environments where students and hospital staff are caring together for patients.

The duality of patient assignments is a prime example. Patients who are assigned to student nurses are also assigned to staff nurses. While dual assignments are necessary, communication breakdowns regarding who will administer the prescribed medications to patients, what medications have been administered, and which medications should be held, have resulted in dose omissions and the administration of extra doses. Thus, the communication between students, nursing instructors, and staff needs to be planned carefully to ensure a model that considers the safety issues associated with dual assignments.   

Data from the reporting programs also show that insulin is among the most frequent drugs involved in student nurse-related errors, particularly with omitting prescribed doses, selecting the wrong type of insulin, administering the wrong sliding-scale insulin coverage, and administering insulin to the wrong patient. Student nurses may not make proportionately more errors with insulin than staff nurses. However, like staff nurses, students and nursing instructors must treat insulin as a high-alert medication and observe the robust safeguards in place to prevent errors. This should include an independent double-check of all insulin doses by a staff nurse before administration. Additionally, organizations should share their list of high-alert drugs and associated error-reduction strategies with nursing instructors to ensure the same level of attention to safe systems and practices occurs when students administer these drugs.

In Table 1 (abbreviated content appears below; table with full content, including error examples, appears in the PDF version of the newsletter), we have listed additional error-prone conditions identified through analysis of student nurse-related errors. The list is not intended to be critical of student nurses or their instructors, nor is it intended to discourage organizations from providing a clinical rotation site for students. Indeed, student nurses often enrich the patient’s experience during hospitalization, and they should be welcomed as part of the patient care team. Rather, the information in Table 1 should be used to stimulate system improvements to reduce the risk of medication errors.

Each practice site that hosts student nurses should meet with the clinical instructors who will be supervising students. The organization’s medication administration procedures and specific error-prone conditions that may exist during clinical rotations should be reviewed, along with system-level safety nets that have been designed to reduce these risks, and safety practices that students and faculty should adopt to further enhance patient safety. In addition to the examples in Table 1, nursing instructors may be able to describe other error-prone conditions that they have observed, which can then be addressed. Nursing instructors should also be invited to attend any orientation programs that cover the organization’s safety goals so they can reinforce related safe practices during clinical rotations.        

Table 1. Conditions the Promote Student-Nurse Related Errors (abbreviated)

Nonstandard Times
Medications scheduled for administration during nonstandard or less commonly used times, including early in the morning, are prone to student dose omissions.

  • Staff nurses should develop a proactive plan with students that clarifies the details and responsibility for administration of each ordered medication and how new medication orders received during the shift will be handled. 
  • Staff nurses and nursing instructors should monitor patient’s MARs and review potential omissions with students.

Documentation Issues 
With both staff nurses and students administering medications to the same patients, dose omissions or extra doses have been administered because students or staff nurses have not properly documented drug administration or reviewed prior documentation of drug administration.

  • Students and staff nurses should be using the same MAR.  Students and staff nurses should bring the patient’s MAR to the bedside and document drug administration immediately after the patient has taken the medications.
  • Encourage students to review all sources of documented drug administration, particularly when patients are transferred from a different level of care or unit.
  • When possible, include students in verbal reports about their patients (e.g., PACU report upon transfer to the unit).  

MARs Unavailable or not Referenced
Students may not consistently use the patient’s medication administration record (MAR) to guide the preparation of medications, and may not bring the patient’s MAR consistently to the bedside for reference when administering medications.

  • MARs should be available to students when preparing and administering medications; worksheets should not be used.
  • Students should prepare medications using only the original MAR and should bring the MAR to the patient’s bedside for verification before administering drugs.
  • Teach students the organization’s process to identify patients using two unique identifiers before drug administration.

Partial Drug Administration
Students may not be administering all of the prescribed medications to assigned patients, particularly IV medications that they may not be permitted to administer.

  • Nursing instructors should provide a daily report to each unit that hosts students regarding the types of medications that the students will and will not be administering.
  • Encourage students to confirm this information with the staff nurse assigned to their patient, and to report drugs that are not given when due.  

Held or Discontinued Medications
Students have not known or understood the organization’s processes for holding and discontinuing medications and have administered drugs that have been placed on hold or discontinued.

  • The organization should review its procedures for holding medications and make any necessary revisions to ensure that the procedure is clear and reliable.
  • Share the organization’s procedures for holding and discontinuing medications with nursing instructors and students. 

Monitoring Issues
Students may not be aware that vital signs and/or lab values should be checked before administering certain medications.

  • Be sure students and nursing instructors know how to access the most recent lab results and are able to obtain them.
  • Work with students to help them identify vital signs and lab data that may alter medication therapy.

Non-Specific Doses Dispensed 
Student nurses have administered excessive doses when they expected the drug to be provided in a patient-specific dose, but pharmacy had dispensed a larger dose or quantity.

  • Pharmacy should dispense medications in ready-to-use, patient-specific doses whenever possible; otherwise provide further instructions on the MAR and the dose itself, if possible. 
  • On MARs, list the patient-specific dose first (before the available dosage strength dispensed, if applicable), as in the following example: “Lopressor 25 mg,” followed by          “25 mg = ½ of a 50 mg tab.” 

Oral Liquids in Parenteral Syringes
Preparation of oral or enteral solutions in parenteral syringes has led to students accidentally administering these products by the IV route. 

  • Pharmacists should dispense all oral liquid products in oral syringes.
  • Medication areas should be stocked with oral syringes.
  • Students should be advised that oral syringes must be used when preparing oral solutions and apprised of the dangers of not doing so.
  • Discontinue IV routes as soon as possible, if appropriate.

Preparing Drugs for Multiple Patients
Student nurses have given medications to the wrong patient, particularly when they prepared more than one patient’s medications at a time and brought medications for two or more patients into a room.

  • Teach students by example to prepare one patient’s medications at a time and administer those medications before preparing another patient’s medications. Stress the risks associated with handling more than one patient’s medications at a time.
  • Teach students the organization’s process to identify patients using two unique identifiers before drug administration.
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