2 Practice Breakdown

Medication Administration

Case Analyses

Historical Case Study #1: The Chemotherapy Protocol

Practice Breakdown in Medication Administration

Historical Case Study #2: A Groupthink Error

Practice Breakdown in Medication Administration

Historical Case Studies #3 and #4: The Right Medication, The Wrong Route

Two Scenarios of Practice Breakdown in Medication Administration

Comparative Analysis

Conclusions

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 (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: