Practice Breakdown: Medication Administration

2 Practice Breakdown


Medication Administration




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:



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 (cy 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:



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.




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.

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Dec 3, 2016 | Posted by in NURSING | Comments Off on Practice Breakdown: Medication Administration

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