"Sentinel Events" : on Surgical

I have to say, the one thing that new nurses have nightmares about when they start their first job is killing their patients. I know I did. They haunted me as a student nurse and it only got worse the first day as an RN, stepping out onto the Surgical Unit. Back then, there were no "preceptor programs" - you were just thrown out onto the floor, on your own. Well, not totally on your own. The other RNs kept a loose eye out for you, if they weren't giving you their extra work.

The Pyxis Med dispensing machine

Nowadays there are plenty of safety precautions in place to stop the errors before they happen. Meds are prewrapped and prelabeled, only to be dispensed if on the patient's Dr Order sheet. MARs are checked nightly (hopefully) and updated. Some hospitals use Pyxis machines that deliver specific medications that you code in and sign out with a thumbprint. Pharmaceutical companies have changed the color codes, the type of packaging and a lot of other things (usually after the barn door closes) to easily ID a medication. Most medications come up from the Pharmacy premixed and well labelled. We now administer a lot of the IV meds by IV pump so as to ensure the correct rate of administration (you don't want to know what we used to let run in free flow). In nursing school we are imprinted with this basic principle: The Right patient, the right drug and dose, the right time and route. It is quite monotonous but there is a good reason for it.

If a nurse that has been working a while says she/he hasn't made a med error ever....she/he is not telling you the truth. Most will not admit to it. Or they have repressed the incident. But, we each have our own little story that is indelibly burned in our minds that, hopefully, makes us better nurses. Statistics show that medication errors are one of the leading injurious things a patient suffers while in the hospital. "Near misses" were never usually taken note of in years past, so it makes sense that there were many mistakes or near mistakes (what we now call ADEs or Adverse Drug Events) that occurred that were never recorded. Possibly still are.

As an LPN, I remember "talk" of one RN on the Medical Unit I worked on that whisked a whole bag of saline within 10 minutes into a tiny fragile elderly woman that already had compromised multiple systems - and didn't report it. Didn't do anything about it. She just hung another bag and re-marked it and carried on. Didn't tell the MD, didn't do anything. Whispers that the expiration due to lung congestion was mostly due to that extra bag of saline. Since it has been 32 years since that incident, I have no clue who the nurse was or who the patient was. All I know is that nothing was done to correct the situation and the nurse did not admit to wrongdoing. Basically, it was swept under the carpet.

This is another story I heard after the fact, but more recently, within the last decade. On an OB unit I worked with an Airhead RN that happened to mix up a PCA syringe with an EPIDURAL syringe. BIG difference. They would have been well labelled. It was caught after the first hour when Airhead went on lunch and the covering RN checked things out immediately when the patient started complaining of weird sensations in her head and found the error. Airhead tried to blame it on whoever put the PCA syringes in the locked cupboard next to the Epidural syringes (admittedly, the hospital wasn't beyond reproach for using the same pump for both Epidurals and PCAs and the same locked cupboard for both) but the bottom line was - the patient was the one harmed, and the RN denied her part in the error.

My own story was a "near miss" and as a new grad RN, ensured for the rest of my career that I would NEVER EVER make another med error. Never. Ever. And I haven't. It still makes my skin crawl 28 years later - thinking about what could have happened. I am hoping that my own admission will caution those that think they are bulletproof. You must never take short-cuts and never think that "it could never happen to me". As recent grads, usually the concept of Standards of Nursing Care is so brand new you can't imagine making similar errors as above. But, let me tell you, one day you will come very close if not actually erring, and it could very well end up in disaster, never mind a free trip (all expenses not paid) through the court system, which you will want to avoid at all costs.

My story: This was during the time that we had 15 or so post operative patients to care for all at once, and when the other RN was on her break, that load would be double. Taking into consideration that most patients were not as acute due to the pre-early discharge era, it was still an ample assignment for one RN- and a new one at that. I was swamped, running around answering bells, getting meds, checking post op vitals, emptying/checking hemovacs, pottying hip replacements,checking toes in casts, tractions - well, anyone that has been on a general surgical unit gets my drift. I am sure I was a blur to most patients as I whizzed through their room.

There was a young woman that had been waiting to have her IV downgraded to a lock. I ran to the cupboard that held the heparin for flush. (Ya, those were the days we used diluted heparin, not saline for the flushes, thus the term "hep-lock" that you hear among "old" nurses) I grabbed the vial that looked exactly like and was marked exactly like the heparin vial from the place on the shelf labelled Heparin flush.
In those days we kept flats of different but commonly used IV vials the cupboard with a label on the shelf of what was in the box above it - you just took what you needed and diluted, mixed and drew it up yourself in a syringe or minibag - you name it - we mixed it - everything from antibiotics, Heparin drips, insulin drips, Potassium ........

Yup, you guessed it. I grabbed a vial of Potassium. I drew up the required amount in a hurry to get to the next task - ran to the room with that Potassium filled syringe, ready to flush the lock. To this day, I don't know what made me stop as I put the needle into the port ( no such thing in those days as "needleless systems") but I thank the "New Nurse Angel" on my shoulder for that "second thinking". I don't know whether it was because the chatty little patient had asked something about the lock, or whether it just miraculously flew through my head that I didn't double check the vial as closely as I usually did.....but I stopped before the plunge, withdrew the syringe and told the patient, one minute while I go and check something. Those were my exact words....

I ran back to the nursing station heart in my throat and looked at the place in the cupboard where the heparin vials are usually kept - above the label HEPARIN on the edge of the shelf. Someone had swapped the places of the heparin and the potassium. In those days the Flush Heparin and the Potassium Vials looked exactly alike – same size/shape/color – even the printing. Sick to my stomach and my heart beating out of my chest, with a shaking hand I shot the K from the syringe into the sink, grabbed a new syringe and heparin vial and drew up the correct flush.
I came one thumb-push from possibly killing someone. It scared me so badly, I can still picture the room, the young woman sitting cross-legged on her bed, the works - just thinking about it - I can even remember the odd color of yellow with brown splashes of who-knows-what on the med room walls and the taste of the med as it hit the sink and aerosolled into the air with the waste.......

In no particular order:

Number one : Check, check and double check. Statistically, the administration of the meds are the second most common reason for AEDs. (wait until you see the number ONE reason. It might shock you) You have heard to check the name on the MAR and the patient hospital band. But -ALSO - If a patient states "I have never taken this pill/shot before": check it out. If a patient questions "what is this pill" and you don't know: check it out (you should have already done this anyway!). If a patient says: "I already got/took this shot/pill" check it out. Ask around. You never know- sometimes meds are given by someone else answering a light when you are busy for a half an hour in another room - and not charted it right away - or at all. They should be. But you just can't count on it.

Number two: If you make a mistake, own up to it and let the charge/MD know right away. There are forms to fill out, counselling with your manager and depending on the facility - reams of other various "stuff" that ensues, but the other option is - it could kill your patient - or not. And quite possibly, there is an antidote, or at the very least, an MD that says "don't worry, that dose won't kill them, it's OK, I will just change the order".
Think of the little twins of the celebrity that could have suffered irreparable damage due to a med error from a care giver if it hadn't been found in time and admitted to.

Number three: The only one you can trust to ensure giving the correct medication is yourself. In other words, don't give a patient a drug that someone hands you because they said you should. You will see other RNs do it. It might even make you a little unpopular or might make others think you are paranoid, but refusing to give a med that is unlabelled or predrawn by someone else - may save your career one day. No matter how much you can trust another nurse and her skills - if she tries to hand you a med for you to dole out to her patient on your way down the hall - or no matter how busy you are that you really can't take the time to get or mix your own.....only trust what you have checked and drawn. Ok, there are times when syringes are well-labelled not coming from the Pharm ..... still - if I am giving a medication, I would rather that nurse waste her own mix - or she can keep it for later use if she is getting that patient back - and I will mix my own. Most nurses aren't - or shouldn't be -offended.

Number four: Know your drugs. And if you don't - Pharmacists are your friends. You can't know ALL the drugs and what they do and all the side effects. And there are so many new drugs and new studies that come out.. but... If you don't know what it is and what it is for - don't give it first and look later. I know I sort of said that in #1 but it bears an extra mention. Look it up NOW - BEFORE you give it - not after. Ya, we all would rather have someone else tell us what it is and what it does, but there is nothing like looking it up yourself that helps you remember for the next time. It can be cumbersome, but there are easy ways to do this nowadays.

Number five: Don't assume what the MD wrote is the correct dosage. Statistically, this is the main cause of ADEs. Even the Pharmacy is occasionally known to send up the wrong drug or mislabeled medication. You are responsible for what you give, including something transposed, written or calculated incorrectly. If it looks strange - ask about it or look it up. If it is a different dosage, there must be a good reason why the drug is given in this dosage or this particular way, and you might want to know this important piece of information while looking after your patient. There are all kinds of "off label" uses for different medications as well as different doses. (for instance, not only is propanolol used as an antihypertensive, it is often used for the treatment of PTSD to calm that "flight and fight" thing your body does. Recently in another nurse's blog who was wondering why the MD gave the patient benadryl for an extrapyramidal reaction to thorazine drug - because it does the same thing as cogentin - counters the effects  )

Number five: Don't depend on any of the safety precautions in place to prevent medication errors. We as the direct caregivers are the best and last barrier to prevent "untoward happenings" in the system.

Some RNs will say bullshit....but they aren't gonna be the ones in court taking the hit for you....it's YOUR license on the line.

Now....let me at my Bailey's and coffee............second thought.....forget the coffee.

Posted by A NURSE at 11:00 AM


More comments that were saved from deletion:


Rachedy said...
We scan meds where I work. I've noticed that a few of the younger nurses will draw up their IV push drugs at the desk and all the syringes look alike. I guess they just scan the empty bottles. Anyway, I asked one little snit how can you remember which is which and she looked at me like I'm an old nurse with memory problems. Sorry, sister, even back in the day I'm not going to know which syringe has Morphine, which has Zofran, which has Pepcid, which has Toradol or Metoprolol. Dumb beatches, they scare me.
May 11, 2010 4:25 PM

A NURSE said...
Yup. Heard of the scanning thing. Whatever works. I have also seen "older" nurses do the same thing...not marking syringes...laziness I guess. ;)
May 12, 2010 1:20 PM

nurseXY said...
The hospitals where I work and have done clinicals have the scan thingie too. The hospital where my wife works doesn't. It's hit or miss.

Drugs scare me, as well they should. I actually have a step ahead in this department as I was a pharmacy tech for nearly 5 years while I got my first degree. The drug knowledge I have from that experience has been so helpful to me in school. Yet another unfair advantage.

Great post BTW, got goosebumps for you...
May 30, 2010 7:09 PM

A NURSE said...
Thanks NXY!! :)