A Recovery Room Error That Almost Cost a Patient Their Life
Medication errors in post-procedural care can greatly affect patients’ safety and lead to undesirable outcomes such as lengthened hospital stays, increased illness, and in severe cases, death. Nurses are the corner stone of medication administration and thus their professionalism, expertise and communication can either improve or decrease patient outcomes (Alrabadi et al., 2021). This analysis will focus on highlighting the root causes of medication errors by nursing staff in a hospital setting, specifically in the post-anesthesia care unit (PACU).
Analysis of the Root Cause
The PACU is the unit where the immediate sedating effects of anesthesia are observed and the patient’s vital signs are monitored (Mert, 2023). The goal is to maintain a stable patient while the nurse observes for any possible complications. From personal experience in PACU, a colleague’s mistake will be analyzed.
The setting is in a busy open-bay PACU at an almost full patient capacity. A 75-year-old- female patient underwent a right shoulder arthroplasty. During recovery, the patient started experiencing significant pain. The nurse approached the anesthesiologist for pain medication orders and the breakdown of the incident is outlined below:
Incident:
Pre-Administration: The nurse received a verbal order from the anesthesiologist for 50mg Fentanyl.
Distraction: While preparing the medications, the nurse prepared 100mg of Fentanyl.
Administration Mistake: The nurse mistakenly administered 100mg of Fentanyl instead of the 50mg of Fentanyl ordered.
The nurse observed that the patient experienced excessive sedation and respiratory depression shortly after administration. The patient’s vital signs showed decreased oxygen saturation levels. This led to jaw thrust maneuver being used, a nasal airway being placed and a non-rebreather mask with 15 Liters of supplemental oxygenation administered. Thankfully, the patient recovered from the medication error with the help of the anesthesiologist and PACU nurses. This incident highlights the critical areas for improvement in medication administration processes within the PACU; thereby, emphasizing the need for better communication, continued education, and sufficient Electronic Health Records (EHR) use.
During medication administration, nurses must have clear communication as a priority. There were a few instances of barriers in communication. The nurse admitted to not reading back the received verbal order which has been shown to decrease medication errors (Salar et al., 2020). The five rights of medication organization (right patient, right course, right plan, right time and right measurement) were not followed by this nurse (Alrabadi et al., 2021). The dose of the medication should have been rechecked and compared with the order and EHR. The hospital policies and nursing leadership are meant to guide and protect the privilege to practice nursing. Perhaps, updates on recent medication error audits were not viewed by the nurse and/or more audits need to be conducted on the unit. Relying on years of nursing practice and old school information as expertise in a field is a dangerous assumption (Salar et al., 2020). The nurse admittedly did not scan the medication prior to administration. The nurse said she had looked at the order to ensure that Fentanyl was to be administered but did not remember to check the dosage ordered. If the nurse had scanned the medication, the EHR could have alerted her to double-check her dosage prior to administration (Upadhyay & Hu, 2022).
Application of Evidence-Based Strategies
To date, there are several evidence-based strategies that have been implemented in hospitals that have reduced medication errors. Hospitals have implemented effective communication, continued education, and the use of EHR as beneficial best-practice solutions. The read back method, which is a part of effective communication, has been shown to significantly reduce medication errors as well as the five rights of medication administration (Alrabadi et al., 2021). Continued education has also been used to fuel nursing education of practicing nurses to reduce medication errors. In hospitals, mandatory competencies are created, exercises in drug chart review and medication reconciliation audits are done at intervals for nursing staff (Isaacs et al., 2020). Furthermore, EHR has been used as a stronghold in nursing practice for over a decade and has been shown to improve nurses’ organization and to increase patient safety. Features such as barcode scanning, wrong dosage and drug allergy alerts have been useful in reducing medication errors by allowing administrators to slow down and double check their actions (Upadhyay & Hu, 2022).
Medication Error Improvement Plan
The goal of this improvement plant is to reduce medication errors by 25% within the next six months by implementing evidence-based and best-practice strategies. The objectives are to champion a culture of safety and communication, to perform medication error audits regularly and to emphasize the use of EHR to support medication safety.
Championing a culture of safety and communication is very important to reduce medication errors. A non-punitive medication error committee with nursing leadership and nursing staff will be developed. This committee will hold debriefings after medication error incidents that will encourage and teach staff safer administration strategies. The committee will also foster recognition for staff who are proactive in safety practices. Creating an environment where nurses feel supported and educated instead of assigning blame is critical to maintain a professional staff. Dr. Salar and the team from Zahedan University of Medical Sciences describes how the more professional a nurse acts the less likely medication errors are to happen (Salar et al., 2020). Personal experiences and observations have underscored that rewarding and recognizing nurses who identify an error before it is made encourages nurses to be upfront with their mistakes.
In order to prevent medication errors, the frequency of these errors need to be tracked with audits. A proposal to the nursing leadership will be made to conduct monthly audits to identify commonalties in errors and monitor overall trends. These audit results will also include attachments of hospital policies and procedures that relate to the medication administration and highlight where breakdown in the procedures occur. The results will be released to staff to increase their awareness of medication administration factors like drug calculation and drug dosages to decrease errors (Alrabadi et al., 2021).
The importance of EHR will be documented as a pamphlet and given to all nurses quarterly. This pamphlet information will be tailored to mitigate the errors in the previous results from the medication error committee and the monthly audits by nursing leadership. Points like scanning drug barcodes causing EHR to alert if there is a possible drug interaction, drug allergy or wrong dose will be emphasized (Upadhyay & Hu, 2022).
Existing Organizational Resources
Leveraging the expertise and resources of data analysts, pharmacists and nurse educators will be helpful in enhancing the effectiveness of the root-cause analysis and in reducing medication errors. This collaborative approach will optimize insights and streamline actional solutions with a broader perspective than nursing. Data analysists are masters at deciphering data and trends and could assist in quantifying and qualifying the medication error audit data. Pharmacists are experts of medication management and can offer helpful strategies to reduce medication errors. Nurse educators are highly trained in strategies to coach nurses. Their expertise in gathering helpful information and creating the pamphlets will be needed to ensure the success of the strategy.
Conclusion
Addressing the root causes of medication errors in post-procedural care requires a comprehensive, systemic approach that incorporates enhanced communication, continued education and sufficient EHR use. By implementing the read back method, mandatory competencies and highlighting the benefits of EHR use, medication errors by nurses can be reduced significantly. Leveraging the expertise of data analysts, pharmacists and nurse educators could provide a more collaborative approach that could improve the success of all proposed strategies to reduce medication errors.
References
Alrabadi, N., Shawagfeh, S., Hahhad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D.,
Abu Farha, R., AlRabadi., & S., Al-Faouri, I. (2021). Medication errors: a focus on nursing practice. Journal of Pharmaceautical Health Research, Volume (12), Pages 78-86. https://academic.oup.com/jphsr/article/12/1/78/6065944
Isaacs, N. A., Ch’NG, K., Delhiwale, N., Taylor, K., Kent, B., & Raymond, A. (2020).
Hospital medication errors: a cross-sectional study. Internal Jounral for Quality in Health Care, Volume (33).
https://academic.oup.com/intqhc/article/33/1/mzaa136/5925732
Mert, S. (2023). The Significance of Nursing Care in the Post-anesthesie Care Unit and
Barries to Care. Intensive Care Research. Volume (3). Pages 272-281. https://link.springer.com/article/10.1007/s44231-023-00052-5
Salar A., Kiana, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals:
A qualitative study. International Journal of Africa Nursing Sciences, Volume (13).https://www.sciencedirect.com/science/article/pii/S2214139120301128
Upadhyay, S., & Hu, H. (2022). A Qualitative Analysis of the Impact of Electronic
Health Records (EHR) on Healthcare Quality and Safety: Clinicians’ Lived Experiences. Health Services Insight. https://journals.sagepub.com/doi/full/10.1177/11786329211070722
By Kerri-Ann Villanueva, BSN, BSC, RN
Founder & Administrator | Nurse-led health education & recovery insights
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