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ADVANCE Perspective: Nurses

Not on My Watch

Published May 23, 2013 6:02 PM by Guest Blogger

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 ( 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% ( 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?


After I had graduated from nursing school and was awaiting State Board results, I was working (as many new grads did at the time) as a med tech. This was before the advent of MAR's, a time when medication was given from a "Kardex" and medication cards were used to "set up" the  meds on a tray.%0d%0a%0d%0aI was working on a nephrology unit which had several 5 bed wards in addition to private and simi-private rooms. I was to give the medicine in the three wards and another graduate nurse was giving the meds in the other rooms. After checking the medication cards to the kardex I set up the medication on the trays to be taken to the wards.%0d%0a%0d%0aThe wards were large and spacious and went from A - E clockwise from left to right. You guessed it, I gave the medicine in each ward starting counter clockwise from the right! After ignoring all the "I've never seen this pill before", "This must be a new one" and "Where is my other pills" it hit me that I had given all 15 patients the wrong medication!%0d%0a%0d%0aIt had only been 3 weeks since graduation and I knew my nursing career was over. I started getting s.o.b., having palpitations and my knees got week. After throwing up I told the charge nurse what had happened. The charge nurse was an old school Diploma graduate from the same hospital where we were working. From my perspective at the time, as well as other new grads, was that she was both feared and respected.%0d%0a%0d%0aAfter I told her what had happened she calmly told me to gather my medication cards and meet her in the room used as an office. She slowly looked at a medication card then looked at me, looked a medication card the looked at me. This went on for what seemed to be an eternity until each of the 50 something cards were looked at. I could already see myself clocking out. Then she quickly looked at each card again and said "I think you have learned a lesson here tonight" and "None of the medications should be a problem for anyone" She also mentioned that the paperwork  and phone calls would keep her tied up for the rest of the night. Then she said "After we leave this room, there is no need for us to mention this again" She added that "At least the 3 patients in the C beds got the right medication."%0d%0a%0d%0aWas the right thing done? I am not going to answer that. %0d%0a%0d%0aI wish I could say that was the last medication error I made but what I can say is that I will never forget the lessons she taught me that night.%0d%0a%0d%0aVDutton @nursingpins

Vernon Dutton, Nursing - R,N,, Hospital May 28, 2013 3:52 AM
New Orleans LA

I do agree! Many times, when getting ready to pass meds, the nurse's phone is ringing, the aid is coming asking questions, casual conversations are being held, and a multitude of other distractors take place. All of this makes it easy to make mistakes. I also agree, in many institutions, nurses ARE afraid to report errors, due to the possibility of negative or punitive outcomes.

Joy May 24, 2013 9:43 AM

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