Should you tell patients a drug error was made?
Of 13,932 ED medication errors analyzed in a recent study, patients or family members were notified about the mistakes only 2.7% of the time.1
This finding was "surprising," according to Julius Cuong Pham, MD, PhD, the study's lead author and assistant professor of the Department of Emergency Medicine at Johns Hopkins University School of Medicine in Baltimore. "This is something to think about," he says.
Error disclosure, however, should not be done by an individual ED nurse, Pham says. It should be a "concerted effort that the whole health care team makes together."
ED nurses at Saint Elizabeth Regional Medical Center in Lincoln, NE, "are very up front about errors," says Libby Raetz, RN, director of the ED. "I have told patients and families that there has been an error many times."
She says generally speaking, "the more severe your errors get, the more other people need to be involved." The involved parties might include risk management, the house supervisor, or the chief nursing officer.
Raetz says in her ED, medication errors are "tiered" using these levels:
- Level 1: An error was made, but there was no potential for an adverse outcome. For example, Mylanta was given instead of Maalox.
- &Level 2: An error was made with no adverse outcome, but there was potential for an adverse outcome. For example, something was given intravenously that should have been given intramuscularly.
- Level 3: An error was made, and there was an adverse outcome, ranging from having to keep the patient in the ED another few hours, admitting the patient overnight, all the way up to sentinel events.
If a drug error does occur, "your first priority is patient safety," says Matt Lowery, RN, ED nurse manager at Presbyterian Hospital in Charlotte, NC. These steps occur in Lowery's ED:
— The ED physician is notified, and the physician evaluates the patient and the medication.
— Patients are advised that an error has occurred, if this is deemed appropriate by the physician.
"We are very up front with patients about any unintended event in patient care," says Lowery. "The nurse and physician are both involved in telling the patient about any occurrence."
- Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2008: In press. Doi:10.1016/j.jemermed.2008.02.059.
Don't inform a patient about this type of error
There are times that it's not a good idea to inform a patient about a drug error, because it could have a negative impact on their care, says Matt Lowery, RN, ED nurse manager at Presbyterian Hospital, Charlotte, NC. For example, an ED nurse misreads a 2 mg dosage order of an anxiolytic medication given to a patient with severe anxiety, and gives 1 mg instead, but the patient's symptoms have resolved.
"This would represent a variance between the order and the dose given and would be documented as such. But it would probably not be beneficial for the patient to advise them of the variance and generate anxiety," says Lowery. "The physician would evaluate the patient and revise the order as the clinical situation indicated."
Are ED nurses left out if errors are disclosed?
It should be a 'team decision'
Nurses often are not included when physicians tell patients about serious mistakes, according to new research involving focus groups of 96 nurses, including emergency nurses.1
Error disclosure needs to be a "team sport," according to Sarah E. Shannon, PhD, RN, the study's lead author and associate professor of behavioral nursing and health systems at the University of Washington, Seattle. The study also found that most nurses were unaware of their hospital's disclosure policies, but they wanted a role in the disclosure process so they could communicate directly to the patient and avoid being blamed for the event.
Shannon recommends the following:
— having an error disclosure policy that creates a "safe harbor," so that anyone can get an objective outsider to look at a case they are worried about;
— giving ED nurse managers training on how to tell patients and families that a mistake has occurred, so they can serve as a "de facto disclosure coach" for emergency nurses.
"Like their physician colleagues, nurse managers currently do not get training in error disclosure," says Shannon. "We recommend that this training include simulation with patient actors."
Patricia Ann Bemis, RN, CEN, author of the Emergency Nursing Bible, Fourth Edition, says the way to "stay out of trouble" is to closely follow your hospital's policies. "At no point should the ED nurse take matters into her own hands and speak to the patient without consulting with the physician and her supervisors," she says. "The decision of disclosure is a team decision."
- Shannon SE, Foglia MB, Hardy M, et al. Disclosing errors to patients: perspectives of registered nurses. Jt Comm J Qual Pat Saf 2009; 35:5-12.