Think You Can't Make Medication Errors?


Check out these actual breaches in drug safety and security for a dose of reality.

medication errors CAREFUL READ Confirm a drug's name, strength or dosage, expiration date and expiration time before administering it.

Are you reading these words thinking a medication error won't happen on your watch because you're good at what you do and can't possibly make mistakes? I know someone like you. Several years ago, a 16-year veteran nurse with exemplary job performance ratings accidentally injected a patient with insulin instead of heparin because the syringes happened to be sitting next to each other. Later, she broke down in my office. "I didn't think I was capable of making that error," she said between sobs. "I discounted the possibility every time I read about similar incidents." Take it from me, errors and oversights can in fact happen to you.

Unlabeled medication vials in the OR had deadly consequences at Virginia Mason Medical Center in Seattle, Wash. The surgical staff there mistakenly injected Mary McClinton with the prepping agent chlorhexidine instead of a marker dye during a brain aneurysm procedure in 2004. Both substances were colorless and clear, and the receptacles containing the liquids were unlabeled. The highly toxic chlorhexidine caused kidney failure, a sudden drop in blood pressure and a stroke. Ms. McClinton died less than a month later. The case made national news, partly because of the hospital's willingness to apologize publically for the devastating mistake and help educate other facilities to avoid similar fates.

1. The unlabeled vials
The surgical team in this case was lulled into a false sense of security, likely because they had never experienced a drug error, and assumed they knew what was in each drug vial. Making the wrong assumption might result in only a few mistakes for every thousand times they're made, but as this example shows, those few mistakes can result in tragedy.

Any medication containers on the sterile field must be labeled — period, end of story — and they must be labeled when medications are drawn. Using pre-labeled containers to draw medications is a dangerous practice. For example, it's common for nurses to use pre-filled saline syringes to reconstitute antibiotics. But pre-filled saline flush syringes look like syringes filled with only antibiotic. Staff can get confused about which syringe contains what, and could end up administering straight saline instead of the needed antibiotics, or vice versa.

Clear and concise communication during drug handoffs is also essential. A verbal and visual confirmation of what's being handed in and out of the sterile field is always a good safety practice:

"Here's the atropine 1mg syringe."
"I'm taking the atropine 1mg syringe."

The person receiving medications should read what the passer is saying by checking the label to confirm what they're being told is correct — she should never take the passer on her word.

Drug labels must contain the medication's name, strength or dosage, expiration date and expiration time. During shift changes at the sterile field, the nurse who's leaving must show the vials used to fill syringes to the nurse who's arriving so she confirms the contents and becomes familiar with the medications used in the case.

Branell Harris, RN, showed up for her regular PACU shift woozy and disoriented. She slurred her words, appeared lost and stared blankly at a computer screensaver for minutes at a time. It was the final straw in a tumultuous working relationship with the Reston (Va.) Hospital Center, which fired Ms. Harris on the spot that day in August 2009. Seven years earlier, Ms. Harris tried to kill herself twice by overdosing on medications. One of her suicide attempts was with Dilaudid, court records show, which she diverted from Reston's supplies.

2. The diversion
Strike a balance between giving your staff access to the drugs they need and having enough security measures in place to prevent diversion. Always maintain drug security and track your drug inventory down to the "each" (automated dispensing cabinets are effective in meeting both goals). The U.S. Drug Enforcement Administration allows a 10% leeway in tracking controlled substance inventories, but that's an overly lenient percentage that you should strive to beat.

Effective anti-diversion strategies also have surveillance components: Audit your employees on a periodic but meaningful basis to see if they're managing medications properly. You must also act quickly — within 24 hours — when questions arise about medication usage within your facility. Did a nurse show up to work woozy and slurring her speech? Is a narcotic missing? Did a patient complain about not receiving pain medication? Investigate all incidents fully, no matter how unbelievable they may seem (friends and administrators aren't immune to the dangers of drug abuse). You need a complete picture of what may or may not have happened before coming to any meaningful conclusions.

Don't be afraid to suspend suspected employees until you come to conclusive answers about incidents in question. You might be wrong on your suspicions, and could end up paying employees for the duration of their suspensions, but you'd be doing the right thing to protect your patients.

Secure all narcotics in an automated dispensing cabinet or locked drawer, and monitor drugs prone to diversion: oxycodone, meperidine and hydromorphone. Have checks and balances in place to track the ordering and use of narcotics — no single person should ever be fully responsible for managing controlled substances. If one person orders the drugs, another person should check them into storage. If one person signs out the medications for use, another person should perform monthly audits to ensure the meds are used properly. The last thing you want is a call from the business office asking why the surgical department is ordering excessive amounts of oxycodone.

In early February 2008, Director of Pharmacy Matt Moss issued a verbal warning to Pharmacy Tech David Grimsley for failing to refill an automated medication dispensing cabinet in the cath lab at Methodist Richardson Medical Center in Richardson, Texas. Two weeks later, court records show, Mr. Moss slapped Mr. Grimsley with a written warning for failing to stock antibiotics in automated dispensing cabinets in the ER, outpatient surgery department and main operating rooms, and for making several errors while restocking emergency crash carts. Later that month, Mr. Grimsley received a second written warning for misfiling 2 anesthesia boxes, but signing off on the contents before delivery to the OR. He was terminated shortly after this third strike for improper medication stocking.

labeled medication NO EXCEPTIONS All medications on the sterile field must be labeled.

3. The stocking errors
Never assume drugs are stocked correctly, even in automated dispensing cabinets designed, in part, to eliminate medication errors by requiring staff to scan bar codes on medications to open corresponding storage bins. Bar codes reduce the likelihood that wrong drugs end up in wrong drawers, but they don't completely eliminate the possibility: You have to scan only 1 vial to open a storage drawer. What if you have 10 items to stock, but one of them is incorrect? It can very easily end up where it shouldn't.

To help ensure medications are stocked correctly, standardize your drugs whenever possible and differentiate look-alike and sound-alike drugs by using TALLman lettering on storage labels and by keeping them in non-adjacent bins. Vials of similar shape or color can also be mistaken for the same product.

Avoid falling victim to confirmation bias. Carefully read entire labels — don't stop once you see the correct vial shape, drug name, label color or dose information. Take a few seconds to ensure all of those elements are correct and match what you're intending to pull.

Have double-checks in place for high-risk products — the person drawing medications should ask someone else to verbally and visually confirm that the medication and dose match what's intended. The bottom line: Always work on the assumption that the medication you've pulled or have been given is wrong, and proceed thinking you must prove it to be correct.

Related Articles

Wired for Success

In her 24 years as a nurse at Penn Medicine, Connie Croce has seen the evolution from open to laparoscopic to robotic surgery....

To Optimize OR Design, Put People First

Through my decades of researching, testing and helping implement healthcare design solutions, I’ve learned an important lesson: A human-centered and evidence-based...