ED nurses saved $100,000 and cut drug errors to almost zero

Mistakes are practically eliminated’ with cutting-edge interventions

(Editor’s note: This is the first of a two-part series on medication errors in the ED. This month, we give proven strategies to avoid drug errors. Next month, we’ll report on what EDs are doing to prevent adverse outcomes by reconciling a patient’s medications.)

Stopping a nurse from giving ampicillin-sulbactam to a patient with a penicillin allergy. Reducing tobramycin dosing for an elderly patient with an elevated serum creatinine level. Correcting an intravenous dose of epinephrine that was 10 times the recommended dose.

These are all medication errors almost made by ED nurses at University of Rochester (NY) Medical Center. They were caught by a pharmacist before they occurred. "All of these could have resulted in potential harm or even death," says Sandra Schneider, MD, ED physician at the hospital and professor of emergency medicine at University of Rochester.

By working with pharmacists to substitute safer and lower-cost medications, the ED saves about $100,000 a year, she reports.

ED nurses are at higher risk than other units for making errors, warns Schneider. "Patients come and go rapidly, and nurses are often administering medication with verbal orders to patients they have not assessed," Schneider says. "The ED has also become the safety net for hospital overcapacity." (Note: The Joint Commission on Accreditation of Healthcare Organizations has issued a Sentinel Event Alert on using medication reconciliation to prevent errors. To access the Alert, go to www.jcaho.org. Under "Top Spots," click on "Sentinel Events" and then "Sentinel Event Alert." The issue is dated Jan. 25, 2006.)

In addition, unlike nurses in other hospital units, emergency nurses usually don’t have much involvement with pharmacists — and this lack of involvement can be very dangerous for patients, says Schneider. "In most EDs, there is no check system, and there is no record kept of near misses," she says. "It is as if the ED is simply out of sight when it comes to medication error reduction."

Inpatient medication orders are written by physicians, checked by nurses, and dispensed by the pharmacy where they are checked again, then checked one last time by the nurse, Schneider explains. "This series of checks helps catch potential errors," she says. "In the ED, the physician writes or gives a verbal order for the medication and it is dispensed and given by the nurse. This eliminates a check — or even two checks — from the system."

At University of Rochester, ED nurses work with a full-time ED pharmacist who double-checks medications before they are given, recommends medication alternatives, and mixes drips. For example, the pharmacist may alert nurses that a patient had an allergic reaction to penicillin in the past and so should be prescribed a cephalosporin antibiotic instead, says Schneider.

"During the times an emergency pharmacist is on duty, we have shown that errors are practically eliminated," she reports.

The ED’s pharmacist program has decreased preventable adverse events, helped to decrease documentation errors, and reduced time to medication delivery during trauma resuscitations, says a recent study.1

During trauma cases and cardiac arrests, having a pharmacist involved with medications is a "huge benefit" for ED nurses, says Lisa Brophy, RN, coordinator for emergency nursing. "When making life or death decisions, there may not be time to realize that the medication may have been ordered incorrectly," she says. "Also, there may be drugs that we are not familiar with, and the pharmacist can educate the nurses on best practices specific to that drug."

The ED pharmacist also helps nurses to identify what substances patients have ingested, adds Brophy. When a 5-year-old boy was brought to the ED by his baby-sitter after ingesting several pills from an unlabeled bottle, the pharmacist was able to immediately identify them as amitriptyline, she says. "We were able to treat faster knowing what the drug was so quickly," Brophy says.

At OSF St. Joseph Medical Center in Bloomington, IL, ED nurses will be implementing a process in which all medication orders are faxed to the pharmacy for review, reports Staci Sutton, RN, BSN, TNS, emergency services manager.

Here are other ways ED nurses are reducing errors:

• Separating inpatients from outpatients.

Unlike the ED, inpatient floors have separate units for cancer patients, pediatric patients, and psychiatric patients, says Schneider. "The medications are common to many patients, allowing nurses to become familiar with dosages and side effects," she says. "In the ED, inpatients of all types and ages are thrown together with acute emergency patients." For example, sustained release medications are used often for inpatients, but they very rarely are given in the ED, and long-acting insulins are used for inpatients instead of the short-acting insulins often used in the ED, says Schneider.

For this reason, admitted patients being held in the ED should be grouped together when possible, says Brophy. "Once the patient is admitted, we have an area that we can move inpatients who are awaiting their bed," she explains.

• Having automated medication dispensers provide a prompt when a dose is selected outside the range of safety.

To stop errors, devise systems that "check the human process," such as placing limits on the dosages of medications that can be removed from medication dispensers, says Schneider.

If a nurse selects 5 mg digoxin, the dosage is questioned, Schneider reports. "It can still be overridden, but it does give a prompt," she says. "This is the next best thing to having a pharmacist there checking the dose."

When there is more than one form of the medication available, such as a sustained release and immediate release, have the dispenser ask the nurse, "Which one do you want?" Schneider recommends.

"Double-checks" for high-risk medications taken from the automated medication dispenser at Sentara Virginia Beach General Hospital require two nurses to put in their identification numbers and passwords, says Kathleen Carlson, RN, MSN, CEN, an ED staff nurse. "This is also required for narcotics if the nurse is not giving the full dose," she says. "It requires a second sign-on to waste the drug, right then and there."

High-risk drugs that require the double-check process are insulin, heparin, adrenergic drip, propofol, chemotherapy, benzodiazepine drips, calcium given intravenously, warfarin sodium, digoxin intravenous, dopamine, dobutamine, sodium nitroprusside, milrinone, 11b\111a inhibitor, magnesium sulfate, neuromuscular blocks, potassium chloride, phosphate, sodium chloride >3%, and thrombolytics.

• Asking ED nurses for suggestions.

At OSF St. Joseph, a form was developed for nurses to report safety concerns and ideas for avoiding medication errors. After checking a box to identify the specific problem, the nurse fills out a section asking, "What can be done to prevent this from happening again?" (See the ED’s Service Excellence Improvement Form.)

"I have received these reports for medication errors involving miscommunication between physicians and nurses, as well as look-alike medications stocked in close proximity," says Sutton, adding that she makes sure to follow up directly with nurses within one week of receiving the report.

She keeps a list of mistakes made in the ED to review at monthly staff meetings. "At times, nurses will report their own errors and discuss them openly," Sutton says.

In addition, a private ED web site allows nurses to use discussion boards to find solutions to system problems involving medications. "This plays out like a chat room,’" says Sutton.

• Simulating actual errors.

At OSF St. Joseph, ED nurses attend inservices where actual medication errors are simulated in real time to see actual outcomes. For example, when nurses hung heparin on a mannequin, it was found that the intravenous pump was programmed for 700 ml per hour, instead of 700 units per hour.

"Simulation assists in the rapid detection of possible mistakes," Sutton says. "It also provides us with real information on administration of medications, since the manikin is programmed to respond accordingly to each medication."

• Creating a "no-talking" zone.

Signs posted around the OSF St. Joseph’s medication preparation area remind everyone that no talking is allowed, says Sutton. "Physicians have also been educated not to interrupt staff in the dispensing area to prevent errors," she says.

At Sentara’s ED, a large mat was placed in front of the automated medication dispenser with a big stop sign saying "Quiet Zone," to keep nurses from being distracted while obtaining medications, reports Carlson. "You cannot speak to the person on the mat."

Reference

  1. Fairbanks RJ, Hays DP, Webster DF, et al. Clinical pharmacy services in an emergency department. Am J Health Syst Pharm 2004; 61:934-937.

Sources/Resource

For more information on prevention of medication errors in the ED, contact:

  • Lisa Brophy, RN, Coordinator, Emergency Nursing, University of Rochester Medical Center, Box 619-14, Rochester, NY 14642. Telephone: (585) 273-1948. E-mail: Lisa_Brophy@URMC.Rochester.edu.
  • Kathleen Carlson, RN, MSN, CEN, Emergency Department, Sentara Virginia Beach General Hospital, 1060 First Colonial Road, Virginia Beach, VA 23454. Telephone: (757) 395-8890. E-mail: kkcarls@aol.com.
  • Sandra Schneider, MD, Professor, Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Room 2-1800, Rochester, NY. Telephone: (585) 275-9490. E-mail: Sandra_Schneider@URMC.Rochester.edu.
  • Staci Sutton, RN, BSN, TNS, Emergency Services Manager, OSF St. Joseph Medical Center, Bloomington, IL. Telephone: (309) 662-3311, ext. 5114. Fax: (309) 661-5109. E-mail: Staci.A.Sutton@osfhealthcare.org.

The Handbook on Storing and Securing Medications provides safe practices, tips, and case studies to help plan, implement, and improve medication storage and security. It includes information and checklists on accreditation requirements. The cost is $75 plus $10.95 shipping charge. To order, call (877) 223-6866 or order on-line at www.jcrinc.com. Click on "Publications" and then "Books." Click on "Patient Safety" and then "The Handbook on Storing and Securing Medications."