What would nurses at ISMP do differently if they returned to the bedside?

Awareness about errors and their causes brings change. One lesson clearly learned is that the most effective remedies to medication errors often lie outside the direct control of individual practitioners. But there are many things individual practitioners can do in their own practice – things that are at least partly under their control - to reduce the risk of an error. As students and fellows move through ISMP, they see the devastation that medication errors have wrought. We repeatedly hear that the experience has changed their practice. Board members and others closely associated with ISMP echo the same sentiment, and it’s a frequent topic of conversation among ISMP staff. We asked the nurses at ISMP to share their thoughts about the changes that they would make if they returned to practice. Here’s what they said:

Enlist the help of patients to safeguard against errors. Patients want to play a role in their own safety but may not know how to become involved. We would remind patients about the importance of proper identification before drug administration (and other procedures) and suggest that they actively participate by stating their name and holding out their name bracelet to help all staff members remember this critical step. We would also spend more time teaching patients about their medications and when to expect them so they could serve as a reminder to avoid omissions and detect errors more easily.

Communicate important information to the pharmacy. We would take the time to send the pharmacy information about the patient’s allergies, height, weight, presenting diagnosis and chronic conditions (listed on admission orders or on a fax copy of the admission assessment) so pharmacists could properly screen all medication orders for safety before dispensing products.

Make pharmacists a valuable member of the team. We would spend time getting to know the pharmacists well and rely on them as an integral team member and a ready source of drug information, even if, regrettably, they were not participating in the day-to-day activities on the unit. As a backup, we would carry a palm-held device downloaded with up-to-date drug information (e.g., ePocrates) so we would never again, during our busiest hours, have to administer a medication with which we were unfamiliar.

Take the Medication Administration Record (MAR) to the bedside. We would prepare only one patient’s medications at a time and leave drugs in their labeled packages so we could compare each to the MAR one last time before drug administration, verify the patient’s name on the MAR, and document drug administration at the bedside.

Minimize the need for error-prone calculations. To determine doses/infusion rates for drugs/solutions with standard concentrations, we would reference dosing tables or allow infusion pumps to perform calculations, if capable. Some may argue that dosing tables are not exact enough because the patient’s weight must be rounded. Others may say that nurses have a duty to calculate their own doses and infusion rates. But calculations are error-prone and a closely approximated dose from a rounded weight is much safer than an erroneous dose. We are not alone on this point. A few months ago, a nurse posted a question on a nursing web site for assistance calculating an infusion rate for 250 mL over 30 minutes. The responses varied significantly. Many cited incorrect and unnecessarily complicated mathematical equations. After more than a dozen confusing responses, one nurse astutely suggested, “Thank God for infusion pumps!!!” With that said, if calculations were necessary, we would certainly have another nurse independently calculate the dose/rate and compare answers to verify accuracy.

Do not sacrifice safety for timeliness. We would no longer consider timeliness the most important dimension of drug administration. While it’s important to start drug therapy as soon as possible and have medications readily accessible for true emergencies, often the clinical need for quick administration does not outweigh the safety of having a pharmacist review the order first. Nor would we rush the drug administration process (or refer to it as a “med pass” because it’s so much more than just “passing” medications). We would be more realistic about pharmacy turnaround time for routine medications and, when able, wait for the pharmacy to mix and dispense IV solutions.

Ask for an independent double check of high-alert drugs before administration. It’s impractical and counterproductive to ask others to double-check all medications before administration. But there’s a handful of drugs (e.g., insulin, heparin), classes of drugs (e.g., thrombolytics, opiates, chemotherapy, critical care drug infusions), or patient populations (e.g., neonatal/pediatric parenteral medications) for which we would request and offer this assistance as a safety net.

Take time to report errors. It’s only through insightful information from those who have made errors that we learn about their system-based causes and remedies. While there’s not much incentive to report errors in a punishing environment, we would make it a priority to report hazardous conditions that could lead to an error (“accidents waiting to happen”) and suggest system-based changes to avoid them. We would actively seek feedback about reported errors or hazardous situations to spur change, and support colleagues who have made errors. Of course, we would make a commitment to report interesting errors or potentially hazardous conditions to the USP-ISMP Medication Errors Reporting Program. All ISMP staff know firsthand how valuable it is to share “lessons learned” with others.

Review the literature for reports of errors that have occurred in other organizations. Too often, errors are a taboo subject. To encourage blameless discussion, we would bring reports of errors that have occurred elsewhere to staff meetings, discuss the likelihood of it happening in our practice site, identify possible system-based causes, and make suggestions for prevention. We would also continue to read the literature routinely to stay abreast of changes in healthcare. As a profession, nursing doesn’t always instill this as a priority. These suggestions are merely an appetizer in comparison to all that nurses can do to help protect patients. You may say, “How unrealistic to have nurses who are not in the trenches make suggestions for improvement.” It isn’t easy to overcome time constraints and staffing shortages faced by all in health care today. But in the end, our greatest teachers are those who have made errors and shared their experiences. They are our source of inspiration for change. We hope they will be yours, too. In the future, we’ll ask our pharmacists and medical director to share what they would do differently to improve safety.