2 Practice Breakdown: Medication Administration
Lisa Emrich
Ensuring the safe administration of medications within the health care system is complex and requires a health care professional’s attention to multiple factors during the process. No one professional can prevent all medication errors. The nurse is at the sharp end of delivery of medications that may have started out wrong in the physician’s order, in the drug packaging, in the pharmacy, or in labeling and packaging similarities. The professional who is attentive to these multiple factors increases the chances for safe medication administration. In order to reliably and safely administer medications, the nurse needs to determine the patient’s condition and/or stability, the actions and side effects of the medication to be administered, the patient’s current medications, the patient’s environment, and the activities that other health care professionals are carrying out on behalf of the patient. Conscious patients should be enlisted to assist with safe administration of medication by clearly identifying themselves to the nurse and being informed of their medications taken at home and in the hospital.
Adverse medication effects can occur even under optimal conditions. A medication combined with other medications, substances, and/or the patient’s physiology has the potential to create life-threatening reactions within the patient, causing temporary or permanent harm to the patient. Computerized information programs on drug interactions, solubility, safe routes, dosages, and complications are an indispensable aid in avoiding delivery of a contraindicated drug to a patient. The nurse must learn to use these systems, and hospitals need to ensure their accessibility to all members of the health care team.
Considerable effort is devoted to mastering the requisite knowledge related to finding the best information on the actions and synergistic effects of medications, incompatibilities, and the ways in which groups and individual patients respond to specific medications. This effort is well spent and essential, because of the array of potential adverse reactions that may occur. Each individual patient’s responses need to be evaluated to determine whether the response to the administered medications is within the expected range or if the patient is having adverse reactions.
Nurses who are knowledgeable about patients’ illnesses and medications are able to provide competent care as they are alert to information sources about the known or expected side effects, medication contraindications, and incompatibilities. Clearly, nurses are well positioned as the patient’s last line of defense to protect patients from unsafe medication administration by using all the available resources pertaining to the particular patient and medication, double-checking all aspects of medication appropriateness in terms of correct dosage, route of administration, timing, purpose, and whether this is the correct patient (Page, 2004).
Identified points within the processing of medications that are particularly vulnerable to practice breakdown noted above include medication prescribing or ordering, dispensing, and administration (Williams, 2004). Nurses’ work takes place primarily at the health care system-to-patient interface, and medication administration is a traditional nursing role within this context. The Institute of Medicine (IOM) discussed these types of practice breakdown as “errors” in its report To Err Is Human (Kohn et al., 2000), in which it described latent errors as those being removed from the direct control of the operator (or in this case the nurse) and include as poor design and poor management decisions or policies. The IOM report describes an active error as an action of the frontline operator in which the results are immediately known. For example, a nurse may convert a latent error to an active error by not recognizing that a medication with a name similar to ibuprofen was erroneously dispensed by a pharmacy. As a result, a nurse may accidentally administer bupropion (Wellbutrin) to the patient instead of ibuprofen.
Investigators discussed possible causes leading to medication errors and nurse involvement:
• …medication errors, an activity directly involving nursing care, have been the subject of many of the studies on error. Within this research focus, studies have typically analyzed errors associated with the order and administration of medications. All too common and preventable are errors such as inappropriate dosage, overlooked known allergies, and wrong drug or route of administration. Such errors often stem from a confluence of factors including environmental distractions, miscommunications, and drug-labeling problems (Maddox, Wakefield, & Bull, 2001, p. 10).
Distractions in the form of noise, interruptions, multitasking, and work overload seriously hamper the nurse’s ability to administer medications safely. Health professionals who report their perceptions of why errors occur frequently cite interruptions and distractions (Ely et al., 1995; Gladstone, 1995). Relying on memory is dangerous, and the nurse, like all members of the health care team, needs to avoid reliance on memory related to drug actions, dosages, interactions, and contraindications. The nurse must evaluate and double-check for errors in the medication order, in misspelled or unclear orders, the manner in which the order was transcribed, and the route by which the medication was dispensed. Nurses often identify and correct a significant number of errors committed by other health care professionals (Page, 2004) before the error reaches the patient. However, no health care team member is ever exempt from unintended medication error.
When the nurse does not check appropriate resources, lacks knowledge about particular patient risks, or for any reason tries to cover up a medication error, this results in the employer’s corrective actions and the potential license sanctions of the nurse’s regulatory board, when such sanctions are warranted.
Regardless of the outcomes of such investigations, these institutional and regulatory reviews are opportunities to examine and evaluate the factors pertaining to the error and to learn more about the role of the various individuals and systems in the error. In this regard, an effective evaluation means that a practice breakdown scenario undergoes review as one system with many subsystems. An open and just culture that does not focus on blame or shame but rather on improving patient quality and patient safety is essential for maximum disclosure and review of all medication errors. A systematic review of relevant information can lead to the creation of methodologic comparisons of the system and of the health care team’s and the individuals’ contributions to the ultimate end point of an error in the administration of medication. These elements can be seen within the context of other systems and other individuals’ behavior, noting the system’s and the nurse’s strengths and weaknesses. Learning from this analysis can be shared with the institutions and with health care regulators and educators. Highly reliable complex systems are alert to potential breakdowns and errors, and respond by cross-checking one another’s performance, avoiding reliance on memory, and constantly analyzing near-misses as well as errors in order to continuously improve reliability and safety (Weick & Sutcliff, 2001).
Many state and federal agencies and organizations have created methods to openly review and evaluate medication errors to improve patient safety. As noted, this is accomplished by identifying, reducing, and ultimately eliminating the opportunities for error at the multiple points in the system of ordering and administering medications (Agency for Healthcare Research and Quality, 2008; Institute of Safe Medication Practices, 2008; The Joint Commission, 2008). For example, the Institute of Safe Medication Practices (ISMP) has prepared a list of medications that subject patients to heightened risk when the medications are erroneously administered (2008). Health care institutions can establish policies and procedures concerning these specific medications in response to well-established heightened risks of particular medications. Further, agencies have also worked to identify and eliminate the use of dangerous abbreviations to decrease the risk for errors associated with misinterpretation of medication prescriptions and orders (Agency for Healthcare Research and Quality, 2008; ISMP, 2008; Ohioans First, 2004, 2009; The Joint Commission, 2008). Institutional failure to attend to these interventions (i.e., automatic alerts to heightened risk medications, use of dangerous abbreviations, lack of automated warnings of drug contraindications and dangerous interactions) place the nurse at unnecessary increased risk for making medication errors, especially in highly pressured work environments.
The Joint Commission’s National Patient Safety Goals (2008) have called for the removal of concentrated electrolytes from clinical units, thus decreasing another opportunity for erroneous administration. For example, potentially lethal concentrations of potassium chloride are no longer stored in patient’s medications or on the patient care unit.
When nurses’ actions result in a primary medication error, the error is seldom due to the nurse’s lack of knowledge about the mechanics of medication administration. Rather, the error tends to be due to the nurse’s knowledge deficit about the medication and its effect on the patient’s clinical situation. The nurse’s inability to recall specific knowledge that should be applied at the time the medication is being administered may also lead to the nurse’s commission of a primary error. With the proliferation of pharmaceuticals, nurses should be discouraged from relying on recall alone, although they are responsible for knowing the major classes and actions of pharmaceuticals. Therefore the questions most pertinent to ask when reviewing the nurse’s activities in each error scenario are:
• •What information should the nurse have checked but did not?
• •What general knowledge about pharmaceutical classes and actions of drugs was missing?
• •Did the nurse properly research and apply the knowledge he/she checked in relation to the medication being administered?
• •What knowledge or pharmaceutical references and medication safety cross-checks did the nurse not have access to that, if the resource had been available at the time he/she administered the medication, would have changed the nurse’s actions?
As automated medication systems of delivery are added, new types of errors are likely to develop (Reason, 1990).
For the State Board of Nursing an important question is: What is the regulatory culpability of a nurse concerning the absence of his/her knowledge in general about the safe administration of medication, and what knowledge about and availability or actual use of the relevant pharmaceutical reference sources contributed to the error? In its recent report, Keeping Patients Safe: Transforming the Work Environment for Nurses (Page, 2004), the IOM recommended that the NCSBN work with constituent boards to create a system of identifying and differentiating nurses’ acts of human error from those of willful misconduct.
Regardless of its root cause, be it a system issue or individual accountability, the resulting medication error jeopardizes patients’ health and well-being, and nurses and other members of the health care team do not usually willfully set out to harm patients. The activities and behaviors of nurses involved in medication errors are explored at the regulatory level when an error greatly harms the patient or goes beyond the usual acts of human error. Both the health care delivery site and the regulatory boards are responsible for examining the complexity and dynamics of the system, the health care community, and nurse and patient variables that contributed to the error. In the TERCAP® instrument, all of these areas are addressed. The database provided by this tool will provide additional information about heightened-risk medication, as well as heightened risks for medication errors associated with the work environment, the collaborative and communication efficacy of the organization, the effective, collaborative functioning of the health care team, and patient conditions such as cognitive impairment that lead to higher risks for medication errors.
TERCAP provides a framework to collect, analyze, and disseminate the factors that comprise and contribute to medication administration errors by accurately categorizing the behavior of nurses and others, and thoughts about their activities at the time of the error. In addition, TERCAP identifies factors that are external to and at the perimeter of the involved nurse’s professional control, but may have contributed to the nursing practice breakdown, resulting in a medication error. It is important that these factors be identified and discussed in the context of the health care environment, the nurse-patient situation, and the resulting error, so that the learning that occurs can be applied to subsequent nurse-patient situations and similar errors may be prevented.
CASE ANALYSES
Errors that involve nurses’ administration of medications are examined in this section and discussed in conjunction with the use of TERCAP. Here scenarios are presented about errors that involve the administration of medications by nurses. Reviews follow these descriptions with explanations as to the ways in which various behaviors, activities, and pertinent clinical information contained within each scenario may be captured by TERCAP.
HISTORICAL CASE STUDY #1: The Chemotherapy Protocol
PRACTICE BREAKDOWN IN MEDICATION ADMINISTRATION
HISTORY
Mr. Michael Neal, a young man diagnosed as having cancer, was being treated with a chemotherapeutic agent in accordance with a highly strict research protocol. The protocol involved intravenously infusing Mr. Neal through his central venous line with twice the standard dose of the chemotherapeutic agent over a 24-hour period. The infusion was repeated once every 7 days. The nursing staff used an infusion pump to regulate the patient’s chemotherapy infusion.
Ms. Jane Jones, a certified oncology nurse, held a senior rank within the institution’s clinical ladder and served as a resource for other clinical staff. She initiated and discontinued Mr. Neal’s chemotherapy infusion during a specific week (as specified in the protocol). However, at the end of the 24-hour infusion period, Nurse Jones saw that 10 to 20 mL of the infusion remained in the bag. Nurse Jones bolused Mr. Neal with this remaining amount of the chemotherapeutic agent in accordance with what Nurse Jones identified as standard procedure regarding leftover amounts of chemotherapeutic agents. Nurse Jones did not document that she had bolused the 10 to 20 mL of the remaining agent, nor did she inform Mr. Neal’s attending physician of the bolused remaining amount.
The following week Ms. Jones again initiated and discontinued Mr. Neal’s chemotherapy infusion. However, by the end of the 24-hour infusion period, only half of the infusion had been administered, leaving approximately 50 to 60 mL of the chemotherapeutic agent in the infusion bag. Ms. Jones again bolused the remaining 50 to 60 mL of medication.
Nurse Jones did not report a possible infusion pump malfunction to the facility’s bioengineering department. Nor did anyone else report this possibility. Further, no information in the documentation indicated that other health care professionals were notified during the tenure of Nurse Jones’s care that the infusion was falling behind.
Two days after the treatment, Mr. Neal reported swelling and other symptoms to his physician. Mr. Neal was later diagnosed with septic shock, liver disease progression, and stomatitis. Nurse Jones, on learning of Mr. Neal’s symptoms, informed the attending physician of her previous administration of the two boluses of the chemotherapeutic agent. It was at this time that she made a late entry in Mr. Neal’s record concerning the boluses of medication.
ANALYSIS
This brief scenario reveals much information about the patient situation and Nurse Jones’s behaviors and activities. She used knowledge from her past clinical experience and situations but inappropriately applied the knowledge to the current patient circumstance. It appears that Nurse Jones’s actions were task oriented and did not reveal the ongoing mindfulness necessary to provide safe nursing care. She did not take into account that the chemotherapy was being administered under a strict research protocol with a much higher than usual level of chemotherapy. It was not apparent that Nurse Jones considered a bolus of the concentration of the chemotherapeutic agent she administered to be highly toxic to Mr. Neal because she had carried out this same practice with much lower concentrations of chemotherapy in the past.
The attending physician was not notified in a timely manner of Nurse Jones’ deviation from the prescribed protocol, either directly by her or indirectly through her documentation. The physician was unaware of the change in dosage and therefore did not alter any procedure relative to Mr. Neal’s initial chemotherapy underdose and subsequent overdose. In this regard, opportunity was lost for immediate rescue of the patient from the medication’s toxic effects.
No mention was noted of the care other nurses provided preceding Nurse Jones’ discontinuing the infusion. However, it would appear that no one noticed that the infusion had fallen behind. Although there could have been a miscalculation of the infusion rate, there was also a possibility that the infusion pump had malfunctioned. The infusion pump was not removed, and this uncorrected situation provided the possibility for further error.
The TERCAP instrument includes a category and subcategories that capture the preceding nursing activities and other factors that may contribute to a breakdown in nursing practice and a resulting medication error. This TERCAP section, Safe Medication Administration, captures information about medication administration and provides space to document what did and did not occur within the activities designated as medication preparation and administration.
In this case, the medication ordered was administered, and it was administered via the correct intravenous route. However, the dose that was infused differed from the dose that was ordered. TERCAP asks for the type of medication error. In this instance, improper dose/quantity and incorrect administration technique are the types of medication errors that occurred.
In this scenario, Nurse Jones did not follow the procedure/protocol as she administered an incorrect dose/quantity of the medication. Further, the situation was additionally compromised by the failure or malfunction of the pump. Because the error also involved the medication infusion rate, the applicable factors may include a miscalculation of dosage or infusion rate, which would also be captured under the category of performance deficit.
After Nurse Jones discovered that the patient did not receive the full dose of the chemotherapy, she unfortunately gave the patient the remaining amount that was left in the bag as a result pump malfunction. This was a new “high dose chemotherapy regime,” and therefore, should not have been administered all at once. The unit nurses had, in the past, given varying amounts of remaining chemotherapeutic agents without obvious patient harm when the chemotherapy dosages were lower. Now that the chemotherapy dosages were so much higher, giving remaining amounts all at once became a lethal, unexamined, and unsanctioned practice. There had been little or no safety orientation and training for the new higher concentration of chemotherapeutic agents. There was no cross-checking of physician and nurse informal practices and no communication about them, so physicians were unaware that nurses were routinely bolusing in remainders of chemotherapy left after 24-hour infusions. Here it is important to note that, based on her documented clinical expertise, the nurse had knowledge of, but did not think about, the risks of the concentrated medication bolus.
The causes, nurse’s knowledge and performance deficit, the machine malfunction, and inadequate orientation and training for the new higher doses of chemotherapy all influenced this tragic error that caused the patient’s death. The nurse’s delayed discussion with Mr. Neal’s physician concerning the initial underdosing or break in the research protocol and the inaction by anyone to notify bioengineering to examine the functioning of the infusion pump or to remove it from the patient care area were related to a culture of low expectations for equipment performance, and a well-established but an unexamined, unsafe informal routine of bolusing in remainders of IV chemotherapy at the end of 24 hours, prior to hanging a new IV of chemotherapy. Had Nurse Jones been informed about the risks of the newer higher concentrations of chemotherapy in a timely update or inservice education, this chain of unfortunate mishaps could have been avoided. The fact that she did not inform the physician earlier about bolusing in the additional chemotherapy was caused by her lack of understanding of the consequences of the higher dosage of chemotherapy, and using an unexamined and unsafe informal practice.
HISTORICAL CASE STUDY #2: A Groupthink Error
PRACTICE BREAKDOWN IN MEDICATION ADMINISTRATION
HISTORY
An attending physician ordered the administration of 50,000 units/kg of penicillin G/benzathine intramuscularly to a full-term infant, Baby Sandy. Ms. Erin Smith, a registered nurse assigned to care for the infant, sent the order to the pharmacy and subsequently received two syringes of penicillin G/benzathine from the pharmacy.
The two syringes contained a total medication volume of 2.5 mL. The unit’s policy concerning infant intramuscular injections allowed for a maximum medication volume of 0.5 mL per injection. After receiving the two syringes of medication, Nurse Smith commented briefly to her unit colleagues about the number of times she would be required to stick the infant. She then began her other unit activities before returning to administer the injections to Baby Sandy.
On Nurse Smith’s return to attend to Baby Sandy, Nurse Smith noted that Ms. Marcy Davis, the unit’s nurse practitioner, and Ms. Margo Johnson, a registered nurse also working in the unit that day, were researching information about penicillin and the injections that were to be administered to Baby Sandy. Their joint goal was to decrease or eliminate the need for Baby Sandy to receive multiple intramuscular injections.
Before filling and dispensing Baby Sandy’s penicillin G/benzathine, the hospital pharmacist called the nursing unit to obtain the infant’s weight. However, unknown to Nurse Smith, Nurse Davis, and Nurse Johnson, the pharmacist misinterpreted the order. He prepared 500,000 units of the penicillin per kg of the infant’s weight instead of the ordered 50,000 units per kg.
The pharmacist did correctly note that penicillin G/benzathine was a viscous solution and therefore labeled the two syringes of penicillin G/benzathine as “IM USE ONLY” before dispensing the penicillin G/benzathine to the nursing unit.
While Nurse Smith was attending to her other nursing activities, Nurse Johnson consulted with Nurse Davis to see if the medication could be administered intravenously, thus negating the need for injecting the baby through multiple intramuscular injections.
Nurse Davis and Nurse Johnson consulted two drug references for “penicillin G” in one reference and “penicillin G potassium/penicillin G sodium” in another. Both of the references for these medications indicated that the penicillin could be administered intravenously. Nurse Davis informed Nurse Smith that both Nurse Davis and Nurse Johnson would administer the penicillin to the infant.
Nurse Davis changed the physician’s order for the route of the penicillin administration from intramuscular to intravenous. Nurse Johnson started the infant’s IV and intravenously administered the penicillin G/benzathine to the infant. Baby Sandy expired.
ANALYSIS
This was a tragic and certainly unintended human error starting in the pharmacy and ending with the nurses in the neonatal ICU. Staying curious and being concerned about unusual amounts and routes of administration are habits of the mind that are needed by all members of the health care team. Errors do not start out to be errors, and in this case the error was neither prevented nor understood until after the medication was administered to the infant.
The medication ordered was indeed the medication administered and would be documented on TERCAP in the section identified under Safe Medication Administration. However, the dose administered was 10 times greater than the dose that was ordered, and the route by which the medication was administered was inappropriate for the viscous medication. Therefore, in responding to TERCAP, the types of medication error one would enter are improper dose/quantity and incorrect route.
Two primary errors occurred in this case. One was by the pharmacist who misread the physician order and dispensed the wrong dose of the medication, and one by Nurse Davis who gave the order for the medication to be administered intravenously. In this instance, the major factors that contributed to the medication error would be coded as “performance (human) deficit” related to the pharmacist’s dispensing error and as “knowledge deficit” related to the nurse practitioner’s mistaken belief that the medication could be safely administered intravenously. The actions of these two health care professionals certainly contributed to the practice breakdown.
Nurse Johnson, however, by not recognizing either of the other professionals’ errors, perpetuated the error sequence by administering the medication. One important question that this case presents is: To what extent is Nurse Johnson culpable as the nurse who administered the penicillin? It is also important to review and discuss these nurses’ decision points within this scenario.
DECISION POINTS WITHIN THE SCENARIO
The first decision point occurred at the time the nurses on the unit received the dispensed medication. All three of the nurses were in agreement that the volume of medication that was to be injected was excessive and recognized/cited the unit’s policy concerning the maximum amount of intramuscular injectate for infants. Despite their collective knowledge that the volume dispensed was five times the acceptable injection volume, the problem-solving attention of these nurses was directed to avoiding the multiple injections rather than questioning the reasons the volume was excessive. This is a good example of a human tendency to identify and fixate on the wrong problem, excessive volume, rather than questioning the accuracy of this amount of volume. A good maxim for medication administration is that packaging is usually congruent with the proper dosage level. When this maxim is violated, the nurse should question the accuracy of the dose. Had the nurses included the pharmacist and prescribing physician in this early discussion, the dispensing decision may have been revealed.
The second decision point concerned the exclusion of Nurse Smith, the infant’s primary care nurse, from the medication administration scenario. In this instance, the extent of Nurse Smith’s involvement in averting the error cannot be determined.
The third decision point concerned Nurse Practitioner Davis, and Nurse Johnson’s consultation of the drug references. The nurses did not identify penicillin G/benzathine specifically in the drug reference, and thus their actions were based on incomplete information. Further, Nurse Practitioner Davis and Nurse Johnson did not observe the “IM USE ONLY” label on the dispensed syringes of penicillin. This unintended concentration of errors provides an important cautionary tale. The effects of the tragic loss of the newborn baby’s life on the parents and on the nurses cannot be underestimated. This costly error needs to be publicized within the institution as a crucial learning point so that such an incident will be less likely in the future.
HISTORICAL CASE STUDIES #3 And #4: The Right Medication, The Wrong Route
TWO SCENARIOS OF PRACTICE BREAKDOWN IN MEDICATION ADMINISTRATION
ADMINISTRATION
The following two scenarios each involved a nurse who administered medication inappropriately. Although the scenarios have some similarities, their differences are quite distinct.
HISTORICAL CASE STUDY #3
Ms. Emily Mugford was a middle-aged woman who was severely mentally and developmentally delayed. She was admitted to a hospital’s medical-surgical unit for complaints of dyspnea, weakness, and anorexia. Her physician ordered an abdominal CT scan.
Ms. Sarah Lynn, a relatively new associate degree graduate, had been working as a registered nurse for approximately 9 months and was in her second week of orientation in her new staff nurse position on the medical-surgical unit of the hospital. She had held a part-time clinic position before starting her current, full-time job and was working 7:00 AM to 7:00 PM on the day that Ms. Mugford was to have her abdominal CT scan. Nurse Lynn had previously been assigned five patients during a shift. However, on the day of the incident she had been assigned 10 patients.
Nurse Lynn and the team leader, Ms. Connie Rand, who was also Nurse Lynn’s preceptor, were in the unit’s medication room. Mr. Sidney Banner, identified as a member of the radiology department, approached them and asked for a syringe. Nurse Lynn initially handed Mr. Banner a 3 mL syringe. Mr. Banner stated that he needed “something bigger.” Nurse Lynn then handed Mr. Banner a 20 mL syringe and asked “if it would do.” Mr. Banner took the syringe and left the room. Before approaching Nurse Lynn and Nurse Rand in the medication room, Mr. Banner had arrived on the medical-surgical unit with a paper cup filled with oral contrast. He took the cup of contrast into Ms. Mugford’s room, set it on the bedside table, and after observing that a 60 mL syringe was at the bedside for use in feeding Ms. Mugford, he went to the nurses’ station to retrieve another syringe to administer the oral contrast. Mr. Banner received the syringe from Nurse Lynn, returned to Ms. Mugford’s room, left the contrast and the syringe at her bedside, returned again to the nurses’ station, and informed Nurse Lynn and Nurse Rand that he did not have time to administer the contrast. He said that he had left the contrast in the room, and asked if either Nurse Lynn or Nurse Rand could administer it.
Nurse Lynn told Nurse Rand that she would go to Ms. Mugford’s room to administer the contrast. On entering Ms. Mugford’s room, Nurse Lynn found the paper cup of contrast sitting on the over-bed table. The syringe that Nurse Lynn had previously given Mr. Banner was filled with contrast and was positioned by the cup on the table. According to Nurse Lynn, she picked up the syringe, removed a needle from her pocket, placed the needle on the syringe, and proceeded to intravenously administer the contrast to Ms. Mugford.
Ms. Mugford immediately went into respiratory distress and cardiopulmonary arrest. No one had witnessed Nurse Lynn’s administration of the contrast to Ms. Mugford, and the information was not disclosed to anyone who responded to Nurse Lynn’s request for assistance when Ms. Mugford’s condition deteriorated rapidly. A resuscitation team was not called because of the presence of a “do not resuscitate” order in Ms. Mugford’s medical record.
Nurse Lynn stated that her initial thought as to the cause of the change in Ms. Mugford’s condition was that she was having an allergic reaction to the contrast. It was not until later in the afternoon, while speaking about the incident with another nurse that Nurse Lynn began to give thought to her intravenous administration of the contrast as being an erroneous act. Nurse Lynn then spoke with the Director of Nursing about the incident at which time Nurse Lynn disclosed her actions.
Further interviews with Nurse Lynn and others revealed additional information about the events that led to the incident. Nurse Rand was Nurse Lynn’s nursing school co-graduate, and had been working in another department of the hospital for about 2 months prior to transferring to the medical-surgical unit. This was the first time that Nurse Rand had served as a preceptor.
Mr. Banner was the secretary/receptionist for the radiology department. He noted that an x-ray technician had mixed Ms. Mugford’s oral contrast in anticipation of the CT scan and gave it to Mr. Banner to take to Ms. Mugford, as was customary practice for the radiology department. A review of the physician’s order for the CT scan in Ms. Mugford’s chart did not reveal an order for contrast to be administered in conjunction with the examination.
On Nurse Lynn’s initial employment at the hospital, her former employer and her nursing school instructors provided very positive recommendations on her behalf. Nurse Lynn described her orientation at the hospital as “following another nurse for a day and being assigned three patients the second day,” noting that she had never heard the terms “preceptor” or “team leader,” and that no one had ever accompanied her when she was providing care to patients. Nurse Lynn stated that the unit manager had met with her, told her “some things,” and had instructed her to find somebody if she experienced trouble. However, information indicates that prior to the incident, Nurse Lynn had met with her unit manager at which time Nurse Lynn reviewed and signed a document indicating that her orientation was going well. When specifically asked about the incident and her actions, Nurse Lynn stated that there was no label on the cup that contained the contrast, and she assumed that it was to be administered by IV push because it was her understanding that only registered nurses administered IV push medications and licensed practical nurses “did everything else.” Nurse Lynn stated she had not previously administered any intravenous medications. Although she stated she had been provided a “skills checklist” that was being checked off, she was not able to produce the list after the incident.
Nurse Lynn was terminated from her position at the hospital and returned to work at the clinic. The physician there reported that Nurse Lynn was “quite green and…had a lot to learn.” However, the physician thought Nurse Lynn worked well at the clinic and attributed Nurse Lynn’s problems to “lack of experience and training.”
HISTORICAL CASE STUDY #4
Another scenario concerned a registered nurse who had been working as a nurse for 4 months. Ms. Kathryn Murphy, a nurse with a bachelor’s degree, successfully completed her 6- to 8-week preceptee orientation 1 month prior to the incident. Nurse Murphy worked in the hospital’s float pool on a day and night rotation. She alerted a physician about her patient, Mr. Steve Shapiro, whose serum potassium level was 2.5 mEq/dL. Not long after the notification, Nurse Murphy stated that Mr. Shapiro’s attending physician called in response to the reported hypokalemia and provided Nurse Murphy with a telephone order to “give 40 mEq KCl bolus.” Nurse Murphy stated that she repeated the order to the physician and the physician confirmed “that’s right.” However, instead of first writing the telephone order in the patient’s record, Nurse Murphy withdrew the KCl from the unit’s stock medication system, measured 40 mEq of KCl, and administered the medication by IV push via Mr. Shapiro’s Groshong catheter.
Mr. Shapiro began convulsing at which time the unit charge nurse came to the bedside. Nurse Murphy immediately informed the charge nurse “I just gave the KCl IV push.” The charge nurse responded “oh my God, you didn’t,” which is when Nurse Murphy realized she had made a grave mistake. Nurse Murphy became visibly upset and was taken to an anteroom.
REVIEW OF PROCEDURE FOLLOWED
The float pool nurse manager came to speak with Nurse Murphy and brought Nurse Murphy the patient’s chart for her to write the KCl telephone order that she received from the physician. A subsequent review of the chart with entries during that time period revealed that in the interim, the physician, who had been summoned to the patient’s bedside, had already written his order as “KCl 40 mEq IVPB × 1 over 4 hours.” Nurse Murphy then wrote the order she received from the physician, as “add KCL 40 mEq to MIV.” In addition, Nurse Murphy made an entry in the nurse notes as follows: “Received T.O. from Dr. Smith to add KCl 40 mEq to MIV and to give a bolus of 40 mEq of KCl. KCl 40 mEq bolus given IV … Dr. called to room.”
The physician’s progress note stated that he was called to see the patient because the patient was in ventricular fibrillation and he had no electrical cardiac activity. The patient’s record also included a “do not resuscitate” code status.
When Nurse Murphy was questioned about the error, she stated that she thought it occurred because she followed the physician’s orders and that she did not know that potassium chloride IV push was contraindicated. Nurse Murphy resigned her position at the hospital and subsequently began work at another facility on the day shift. She did not disclose the medication error to the new employer, and at the time of this error there were no State Board of Nursing databases that tracked individual nurses’ errors before they started a new job (see Chapter 10). Nurse Murphy has not incurred further practice problems, her evaluations have been positive, and she states she carries a drug reference book with her at all times.
COMPARATIVE ANALYSIS
In these two cases, both nurses were relatively inexperienced, which contributed considerably to the medication errors that occurred. Had Nurse Lynn relied on the basic standard of verifying medication orders, verifying the medication, and ensuring aseptic technique, she would not have administered the oral contrast intravenously. A more serious basic question of deep learning or formation in nursing school about sterile and nonsterile fields underlies these acts. The lack of sterility of the contrast medium, and the viscosity and opaqueness of the solution, should have been have been sufficiently salient to Nurse Lynn to deter her automated or routinized, action without thought. No human being, regardless of experience, is immune to lapses of thoughtfulness; however, professional formation and overtraining of habits of thoughts and actions in some essential errors should create an additional layer of protection to the actions of any well-prepared professional, regardless of the field. Each field has its own central habits and tenets, and sense of salience, and habits around “sterile, dirty, and clean fields” are among the basic habits of thought and action in nursing. Nurse Lynn’s response about acting on role descriptions of what registered nurses (RNs) do and what licensed vocational nurses (LVNs) do, reveals a “job description” understanding of the RN role and a lack of grasp of the professional accountability for knowledge and judgment of both levels of nursing practice.
Further, information suggests that Nurse Lynn’s orientation was not well designed and that Nurse Rand, because of her own inexperience, was an inappropriate choice for Nurse Lynn’s preceptor. However, Nurse Rand later testified that she felt competent to be a preceptor.
The question remains that if Nurse Lynn’s absence of appropriate insight, knowledge, and judgment had been detected during the first week of her orientation, her practice would likely have been more tightly monitored and documented than it was. These orientation concerns would be important to document by the state board investigator using TERCAP.
Nurse Murphy was conscientious about her responsibilities but was inexperienced as a staff nurse. She had successfully completed her orientation period, and documentation was available to attest to this action. She asserted good judgment in promptly reporting Mr. Shapiro’s hypokalemia to the physician but did not possess adequate knowledge of the risks of intravenous potassium before she administered this medication. The nurse’s knowledge deficit was compounded by the availability of the concentrated electrolyte through the unit’s automated dispensing system. It is noteworthy that this particular error has since been rendered almost impossible to make because concentrated electrolytes are no longer stored on patient care units.
Nurse Murphy was accurate and responsible in reporting all of her actions to the charge nurse at the time of the incident and realized, with the charge nurse’s response, that her actions were erroneous. However, Nurse Murphy affirmatively stated that she was following the physician’s verbal order to give the “KCl bolus,” which was different from the order the physician wrote in the patient’s record immediately after being called to the patient’s bedside.
It is speculative that the physician abbreviated the telephone order that was given to Nurse Murphy, possibly expecting her to further interpret the order. However, no information is available that this was confirmed by the state board case investigator. If, indeed, this “shorthand” communication was the medium of communication, it illustrates the ways in which communication or miscommunication often plays an active role in medication errors. It is likely that the physician thought of the slower administration of KCl as a boost or “bolus,” although this is not the common use of the term “bolus” for nurses.
The NCSBN’s Model Administrative Rules (2004) delineate the general requirements of states’ nurse practice acts. These include the standard that each registered nurse clarify orders when needed, especially “phone orders” (first by clarifying on the phone and second by looking up the safety and reasonableness of the order). Currently undergraduate nurses have little experience in phoning a doctor for a provider order (Benner, Sutphen, Leonard, & Day, in press). This incident illustrates the need for instruction and at least simulated practice in obtaining emergency medication for a rapidly changing or dangerous patient condition. From Ms. Murphy’s perspective, she very well understood the physician’s order to give the “KCl bolus,” and erroneously she considered this to be sufficient warrant for her actions with no additional cross-checking of her colleague’s order.
In Reason’s (1991) theory, the holes in the Swiss cheese lined up perfectly to allow this tragic error to occur. Concentrated vials of KCl were then readily available on the patient care unit; the physician was unclear about the nursing meaning or interpretation of the word “bolus,” and he was unaware that he was speaking to a relatively inexperienced nurse; the new nurse did not recall and did not check for drug administration, dosage, routes and time, and dilution required for KCl, and operated from a stance of ignorance or lack of memory about KCl and blindly adhering to a physician’s order without verifying its reasonableness and safety before administering the drug.
Nurse Murphy is responsible for knowing that a concentrated intravenous dose of KCl is lethal and is equally responsible for looking up an unfamiliar drug before administering it. She did not perceive her professional responsibility to verify the accuracy and safety of all medical orders before carrying out the order. This error occurred before KCl was assigned “red alert” status and made unavailable in concentrated doses on nursing units. These “system” corrections would have closed a crucial hole in the system “Swiss cheese” alignment and prevented this tragic error. Professional responsibility and accountability require that Nurse Murphy look up the indications, dangers, and actions of KCl as required by the Model Administrative Rules (NCSBN, 2004). Nurse Murphy maintains her nursing license and has not incurred further practice problems, her evaluations have been positive in a new place of employment, and she states that she carries a drug reference book with her at all times.
CONCLUSIONS
These case histories raise persistent questions as to the reasons the nurses were not quick to communicate with primary care physicians and referring physicians. To what extent do communication barriers exist, and is this barrier interpersonal, interprofessional, or physical in nature? Why didn’t the nurse check drug references for information about KCl before administering it? Is pharmacologic information readily available to nursing staff, and if so, is it sought and used? What remedial and regulatory actions are appropriate when a nurse is not cognizant of her lack of knowledge? Institutional in-service education should be stressing the importance of routing verification and checking of the safety of all health care provider orders, and this should be an absolute requirement verified by a reporting system for new health care provider orders. A lack of institutional responsibility for patient safety is demonstrated by the lack of these ongoing patient safety education measures. These two cases affirm an educational gap in preparing nurses to safely make a case for a physician order and following through with verification, and then checking the safety and appropriateness of the physician order. Active ongoing inquiry of all professionals is paramount to patient safety (see Cullen et al., 1997).
The safe administration of medications and ongoing investigation of medication errors to design the system to better support accurate medication administration, and ongoing continuing education of all health care professionals on the administration of medications, are all required to improve patient safety in the administration of medications. As Henriksen et al. (2008) point out, human factors research is needed in all areas of nursing practice but especially in the area of the administration of medications:
Many nursing work processes have evolved as a result of local practice or personal preference rather than through a systematic approach of designing a system that leads to fewer errors and greater efficiency. Far too often, providers and administrators have fallen into a “status quo trap,” doing things simply because they always have been done that way. Human factors practitioners, on the other hand, take into account human strengths and weaknesses in the design of systems, emphasizing the importance of avoiding reliance on memory, vigilance, and follow-up intentions—areas where human performance is less reliable. Key processes can be simplified and standardized, which leads to less confusion, gains in efficiency, and fewer errors. When care processes become standardized, nurses have more time to attend to individual patients’ specialized needs, which typically are not subject to standardization. When medical devices and new technology are designed with the end user in mind, ease of use and error detection or preventability are possible, in contrast to many current “opaque” computer-controlled devices that prevent the provider from understanding their full functionality (Henriksen et al., 2008, p. 2).
Evaluating practice breakdown and system redesign and specifically designed educational efforts will reduce medication errors. Ongoing quality improvement is a professional responsibility that requires ongoing examination and reexamination of the contributions made by the system, health care community member, and nurse in regarding each practice breakdown event that occurs (Wolf, 1994). Individual, practice communities, and systems of health care delivery must all receive adequate ongoing quality improvement efforts to improve patient safety.

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