Not on My Watch
By Diane M. Goodman, APRN, BC, MSN-C, CCRN, CNRN
A group of nurses had gathered to inhale a quick lunch. The topic for the day was medication safety. We reviewed a recent article (posted online) that discussed the importance of minimizing interruptions to nursing workflow, particularly during medication administration. In the posted scenario, a nurse had prepared chloral hydrate as a pre-medication, and had the medication ready to dispense on her mobile cart. While engaging in a brief social conversation, the nurse inadvertently drank the sedative instead of her coffee, which she also kept on the cart. My peers laughed and laughed, thinking the scenario was so bizarre that nothing similar would ever happen to them. "Not on my watch" they insisted; they were deliberate, attentive and safe while passing medications.
But how close to the truth IS their declaration? Medication errors continue to be an issue, in spite of multiple safety mechanisms, innovative practice strategies and organizations designed to prevent them. In one specific survey of bedside RNs, 54.4% believed medication errors are under-reported, for a host of different reasons (nurses.info/services). Retaliation is often cited as a prime reason not to report, for if an individual nurse has a pattern of errors, he/she will likely be considered unsafe and a potential risk to the organization.
Safety in administering medications is not a new problem or unique to the U.S.. Australia, for example, experienced 140,000 medication errors per annum as early as 2003, prompting 100 hospitals to launch a safety campaign designed to reduce errors by 50% (nurses.info/services). A decade later, their work continues on medication safety. Similar initiatives in the U.S. have included CPOE (computerized physician order entry), medication reconciliation, unit-dosing and interdisciplinary teamwork.
The bottom line is simple. As long as medication administration depends on a human workforce, human error will continue to be a factor. We can be attentive, thoughtful, diligent and have razor sharp focus, but we cannot be perfect beings. We must understand potential risks in order to minimize error.
A medication error I cannot forget occurred years ago, when one of my intensive care patients coded. Another pump was beeping, but try as I might, I couldn't leave what I was doing. One of my peers added the next infusion, inadvertently doubling the rate while doing so. The patient I was enthusiastically trying to save continued to require emergency intervention, so I didn't have an immediate opportunity to double-check the infusion. Hours later, as the shift was ending, I had forgotten.
The error, however unintentional, occurred "on my watch." To compound matters further, the error was not caught for an additional two days (while I was off), until the patient began to exhibit signs of toxicity! My signature was on the infusion sheet, so I owned the error, which has continued to haunt me for years. No retaliation was involved, except my own incredulity at how such an error could occur, particularly when I couldn't immediately double-check my peer.
So laughing at the lunch table aside, any of us could be the next to drink chloral hydrate. Errors continue to occur. As nurses, we cannot be cavalier and pretend it only happens to the "other guy." We must continue to be conscientious, focused and aware of the risk. Before we can say "not on my watch," we have to be willing to report errors, examine risk factors and become meticulous safety freaks.
I'm certain I am not the only experienced nurse with a story to tell. Are you ready to share one of yours?