ED nursing near misses can be used as red flags

Drug or dosage near misses are common in EDs, but these tend to be swept aside by nurses. How can you call attention to these near-disasters so others can learn from them?

"This is a struggle for many nurses, administrations, and organizations," says Chris Costello, RN, director of emergency and obstetrical services at Mount Desert Island Hospital in Bar Harbor, ME. "Nurses have a wonderful opportunity to help others learn from everyone's mistakes."

Switching to a "nonpunitive" culture was easy for administration, but not so for ED nursing staff, according to Costello. "When I find out about a near miss, I have to work with the staff member to make out a near-miss report," she says. They are sometimes very reluctant."

Costello always keeps a mental note of any errors or near misses she encounters while precepting in her ED. "I make a point to review these, to help nurses learn from previous mistakes," she says. She incorporates these mistakes in practice scenarios during skills days and when reviewing competencies.

All errors and near misses are reviewed by the hospital's Nursing Shared Governance Practice Council. However, Costello says, "by no means do all nurses get the benefit of these reviews." For this reason, ED departmental errors and misses are always reviewed at staff meetings. "This is sometimes done anonymously, and sometimes the staff member gives a verbal synopsis of the event," she says.

"Minimizing errors in mediations and treatment of pediatrics cannot be overemphasized," says Costello.

During a staff meeting for ED nurses, a pediatric intensivist from the medical center where most patients are transferred discussed recent cases of pediatric seizures, fevers in infants 0-60 days old, status asthmaticus, and pediatric head injuries. Some of these involved ED nursing near-misses.

The ED nurses had a lot of questions for the intensivist, mostly regarding fever and status asthmaticus. Algorithms for these conditions were provided, which were added to the ED's pediatric code cart reference book. "This was incredibly helpful to the staff," says Costello. "He mostly pointed out how well the patients were cared for in advance of the transfer."

The case review also pointed out practices that needed improvement, however. For example, an underdose of a stabilizing medication was given to a patient. This underdose happened because of a misunderstanding of a verbal order given by a physician who was on the phone arranging the transfer.

"We were able to discuss the importance of closed-loop communication," says Costello. "Another thing that was brought up, that we did not necessarily think about at the time, was that the child had been ill," Costello says. "We should have considered H1N1 precautions."


For more information on learning from ED nursing near misses, contact:

  • Chris Costello, RN, Director of Emergency and Obstetrical Services, Mount Desert Island Hospital, Bar Harbor, ME. Phone: (207) 288-5081, ext. 1313. E-mail: chris.costello@mdihospital.org.