ED nurses cut drug errors by speaking up for safety’

A nurse is about to give the incorrect dosage to a patient, but she catches the error beforehand — and you notice it’s because two "sound-alikes" are stored next to each other. A physician orders diphenhydramine for a patient with a "Triple C" overdose, but you know an anticholinergic shouldn’t be given.

Would you speak up about these incidents?

ED nurses have reduced errors and near-misses with a "speak up for safety" campaign at Edward Hospital in Naperville, IL, reports Sharron Chivari, RN, MSN, CEN, clinical leader of the ED.

"Nurses are encouraged to speak up without fear of reprisal. Walk through our halls and you’ll see "Speak Up" posters reminding everyone that it’s really OK to say something. We applaud nurses that have the confidence to address their concerns," says Chivari. ED nurses view a videotape, developed in-house, that educates staff on appropriate ways of speaking up about safety concerns, she explains.

When a new ED nurse thought a dose of morphine was too high for her patient, she spoke up — and held her ground even after the physician explained that the higher dose was needed for pain control. "The physician was taken aback and politely asked another nurse to give it instead, but her co-workers refused to do so based on the same rationale," says Chivari. As a result, the physician agreed to give half the dosage, and the patient’s pain was relieved.

This is an example of the "Speak up for Safety" campaign in action, says Chivari. "It was not only pleasing to have such a new nurse speak up, but have others willing to support her in her efforts to do the right thing."

ED nurses need to work collaboratively to ensure the patient is not harmed, says Trudy Meehan, RN, CHE, director of emergency medical services at Wyoming Medical Center in Casper. "We are accountable to the patient for our actions and in protecting our license," she says. "However, doing so in a professional manner, rather than an antagonistic manner, is key."

When voicing concerns to colleagues, do the following:

• Ask a "coach" for help.

If you’re uncomfortable approaching a co-worker, ask a colleague to be a support person during the interaction, suggests Meehan. "If there is time, role-play with them so you feel more comfortable," she says.

At Edward Hospital, ED nurses occasionally ask charge nurses to coach them or even accompany them, says Chivari. "Charge nurses can validate the concern by their own experience and assist the nurse in organizing their approach." For example, a coach might instruct a nurse to say, "Dr. Smith, I’m uncomfortable with the order as it is written. Could we discuss this, please?"

"This is a nonthreatening way of presenting the dilemma and gives the physician the opportunity to clarify or rationalize the order or perhaps change it altogether," says Chivari.

• Ask for clarification.

Clarification sometimes can clear up a misunderstanding, advises Chivari. "Often a physician will catch the mistake’ they’ve made or be able to justify their reason for an unexpected order," she says. For example, if you are uncomfortable discharging a patient home, give the reason, such as, "The patient is still short of breath with low oxygen saturation levels," or "The patient is unable to ambulate without assistance," she says.

Before you take the next step and go up the chain of command, make your colleague aware of the need to do so, recommends Chivari. "Appropriate, organized, professional communication is of paramount importance," she says. "It must be remembered that this isn’t a power struggle or a means of achieving some other ulterior motive. The concern should be altruistically for the patient’s safety."

If you believe an order to be unsafe, you also can contact the pharmacist and review the order, suggests Meehan. "If they too feel it may be an error, ask them to assist you in discussing the situation with the physician," she says.

• Use a double-check process.

Many near-misses involving dosage errors and intravenous drips have been caught by other nurses due to a new "double-check" policy, says Chivari. "Nurses must double-check the dose mode of the pump with another nurse. This makes for more of a team approach to nursing rather the usual feeling of being left on your own," she says. (See the ED’s policy for administering intravenous medications with continuous infusion solutions or dilutions.)

Recently, the second nurse called in to verify a dose caught a mistake with a nitroprusside drip that was set at 5 mcg/kg/min rather than 0.5 mcg/kg/min. "It was on a critical patient, the nurse had multiple orders, and the patient was unstable," says Chivari. "The patient would have received far too much of this medication and quickly become hypotensive."

• Increase your comfort level by asking questions.

Avoiding an interaction because you are uncomfortable may be easier, but this is not in the best interest of the patient, says Meehan.

She recommends approaching physicians on a regular basis with pertinent questions about diagnosis and treatment. "This allows you to become comfortable approaching physicians positively," she says. "Then should a situation arise where you need to question them on a possible error, you will be more comfortable doing so and they will not feel threatened — a win-win for both of you."


For more information about patient safety in the ED, contact:

  • Sharron Chivari, RN, MSN, CEN, Clinical Leader, Emergency Department, Edward Hospital, 801 S. Washington St., Naperville, IL 60540. Telephone: (630) 527-3000. Fax: (630) 527-5018. E-mail: schivari@edward.org.
  • Trudy Meehan, RN, CHE, Director of Emergency Medical Services, Wyoming Medical Center, 1233 E. Second St., Casper, WY 82601. Telephone: (307) 577-2231. Fax: (307) 577-7857. E-mail: tmeehan@wmcnet.org.