Study: Temporary ED Staff Twice As Likely To Be Associated With Medication Errors That Cause Harm To Patients

Consider orientation programs, seasoned guidance to ensure temp personnel are prepared to deliver quality care

This article originally appeared in the December 2011 issue of ED Management.

Busy EDs are increasingly relying on temporary staff to cope with nursing shortages, unanticipated spikes in volume, and other personnel challenges, but the practice is coming at a steep price, according to research from Johns Hopkins University (JHU) School of Medicine in Baltimore, MD. A new study, led by Julius Cuong Pham, MD, PhD, an assistant professor of anesthesiology, critical care, and emergency medicine at JHU, suggests that temporary staff working in the ED are twice as likely as permanent staff to be associated with the kind of medication errors that actually harm patients.1

While researchers did not look at the specific reasons for this association, there are some obvious possibilities. Temporary staff may be unfamiliar with regular policies and procedures, for example, but there could also be deeper problems involved, says Pham. "A hospital may be experiencing a lot of turnover of regular staff, it could be rapidly expanding, or perhaps it is taking in more patients than it can adequately take care of with its normal staff," he says. "This may be a sign that the organization's local resources are overwhelmed."

Whatever the underlying causes, the study's findings suggest that ED managers should consider safeguards to ensure that the temporary nursing staff are adequately prepared and positioned to deliver high-quality care.

Take Advantage of Former Full-timers

Pham decided to take a closer look at the issue because he saw that not only is the use of temporary staff increasing in the nation's hospitals, but experts are predicting that the current nursing shortage will become more acute in the next few years with anticipated retirements. Also, through JHU's affiliation Medmarx, a national Internet-based medication error reporting system, Pham and his research colleagues had access to a treasure trove of data that could shed light on this issue. Pham felt that any association between the use of temporary staff and medication errors would be felt most acutely in the ED because of the unique pressures that occur in the emergency environment.

By completing a cross-sectional study of Medmarx data from between the years 2000 and 2005, the researchers found that a total of 23,863 medication errors were reported in the EDs from 592 hospitals. Further, the researchers reported that the errors committed by temporary staff were more likely than the permanent staff errors to require patient monitoring, result in temporary harm, or to be life-threatening.

Researchers emphasize that it would be a mistake to place the blame for these errors on the temporary staff themselves. Instead, Pham suggests that hospitals should carefully assess the way they are using and training temporary staff to see if any revisions are in order. "Depending on how often you use temporary staff, it may be more [financially] beneficial to hire permanent staff to fulfill these roles," he explains. While temporary staff typically earn more per hour than permanent staff, hospitals usually don't pay for their benefits.

However, Pham recognizes that many organizations utilize temporary staff not because of any financial advantage, but to cover personnel shortages. "In these cases, hospitals are in a difficult position because if they don't hire temporary staff, then the positions go unfilled and they are short-staffed," he says.

One strategy that JHU uses with success is to rely on temporary nurses who used to be full-time employees within the system. "Some people just like to be temporary staff because of the flexibility in their hours and the fact that they don't have to be involved with some administrative tasks," he says. "If they can get their benefits elsewhere, the option can be appealing."

In addition, JHU provides an extensive training period for temporary staff who have never worked at JHU or are unfamiliar with a particular division or department, says Pham. "We give them quite a bit of time so that they are oriented to our local systems, our local culture, and how we do things before they can practice on their own," he says.

Link Temporary Staff With Seasoned Veterans

Unanticipated surges in patient volume can occur, but oftentimes such surges are predictable, explains AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, the 2011 president of the Des Plaines, IL-based Emergency Nurses Association and clinical director of emergency nursing at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center in Philadelphia, PA. "If you are located in a winter resort area, there is just no way around having temporary help because your census can go from 40 patients one day to 140 patients the next day because the season has opened," she says. "The best thing that hospitals can do is plan to on-board their temporary staff and ensure that these nurses have adequate orientation."

In addition, Papa stresses that ED leaders need to make sure that a process is in place to ensure that every temporary staff person has a seasoned nurse he or she can go to with any questions or concerns. Ideally, the mandate for this kind of practice should come from ED leadership, but charge nurses should be responsible for actually connecting a temporary nurse with a resource nurse and for making sure that this connection is effective. "The charge nurse should make rounds and ask how things are going," says Papa. "If the individual who was assigned to be a temporary nurse's resource person is not stepping up to the plate, then the charge nurse has to have the authority to step in."

This type of model provides temporary staff with an additional resource person because they can also go to the charge nurse if they need assistance or information. This kind of support is essential, stresses Papa. "What happens sometimes is the culture is not welcoming to new on-boarded or temporary nurses," she says, explaining that this can make temporary staff reluctant to ask questions or voice concerns. "Sometimes there is just a sense of resentment ... or a tendency for what we call lateral violence. And if that culture is allowed to permeate through the department, then the bottom line is that the person who is the biggest loser from all of this is the patient."

By the same token, however, ED leaders need to recognize that it can be distracting and burdensome to be constantly bringing temp personnel up to speed. To get around this problem, Papa notes that administrators need to find ways to show their appreciation for valued nurses who are capable and willing to provide this kind of seasoned guidance. "This can be as simple as throwing a party, providing gift cards, or establishing a preceptor award," says Papa. "There just needs to be some type of recognition."

Effective communications and a welcoming culture will go a long way toward eliminating errors, but Papa says it also helps to have a pharmacist as a resource in the ED, or at least a pharmacy hotline that nurses can call when they need a quick answer. "In the ED, you can't wait an hour for an answer, and sometimes 10 minutes is too long to wait, so this has to be a priority for the hospital," she says. n


1. Pham J, Andrawis M, Shore A, et al. Are temporary staff associated with more severe emergency department medication errors? Journal for Healthcare Quality 2011; 33:9-18.


For more information, contact:

• Julius Cuong Pham, MD, PhD, Assistant Professor of Anesthesiology, Critical Care, and Emergency Medicine. Johns Hopkins University School of Medicine, Baltimore, MD. E-mail:

• AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, President, Emergency Nurses Association for 2011, and Clinical Director of Emergency Nursing, Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center, Philadelphia, PA. E-mail:

• Medmarx ( is a national registry of adverse drug events that is compiled through a subscription-based, voluntary reporting system offered by Quantros, Inc., in Milpitas, CA. Phone: 877-782-6876. Web: