A 32-year-old G2 P1 undergoes an elective induction of labor at 39 weeks. She’s admitted at 6 a.m. The night nurse quickly completes her admission and starts the induction. Oxytocin is ordered along with a mainline IV of D5LR running at 125 ml/hr. On this unit, oxytocin is typically run on a pump, while the main line flows freely at a rate that is eyeballed by the nurse. In error, the nurse switches the two IV bags, putting the main line on a pump while the oxytocin is free flowed. The error isn’t caught until the day shift nurse arrives 20 minutes later, by which time the patient is contracting every two minutes and recurrent late decelerations are noted on the external fetal monitor. Fortunately, due to the astute care of the incoming senior nurse, intrauterine resuscitation measures are begun, and the error is quickly corrected. Ultimately, there is no harm to mother or baby.
This is one example of medication error and its impact on patient safety. The following article provides an overview of medication errors and strategies to improve medication safety.
Medication errors
Medication errors have been defined as
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (Hughes & Blegan, 2008, para. 4).
Studies show that preventable, drug-related injuries in hospitals are as high as 400,000 per year, creating an estimated financial burden of $3.5 billion (American College of Obstetrics and Gynecologists, 2016). The importance of medication safety cannot be understated, given that current challenges in healthcare include increased workloads, short staffing, inadequate patient safety and quality education for healthcare providers, illegible prescriptions, and faulty dispensing systems (Hughes & Blegen, 2008). In addition, human factors, such as fatigue, distractions, and communication failures can also contribute to medication errors (American College of Obstetrics and Gynecologists, 2016).
Strategies to improve medication safety
The medication process involves five stages: (a) ordering/prescribing, (b) transcribing and verifying, (c) dispensing and delivering, (d) administering, and (e) monitoring and reporting (Hughes & Blegan, 2008). Most medication errors occur at the ordering phase or the administration phase, and include causes such as wrong dosage, unknown allergies, illegible handwritten orders, and incomplete electronic prescriptions (American College of Obstetrics and Gynecologists, 2016).
Medication safety strategies target the various stages in the medication process. Mitigation strategies include the 5 Rights of the medication administration process, bar code scanning, independent double-check for high alert medications, labeling and tracing IV lines, electronic order entry system, electronic prescribing (e-prescribing), and allergy alerts.
Basic medication safety starts with individuals following the “5 Rights” of the medication administration process: the right patient, right drug, right dose, right route, and right time. This fundamental safety practice is part of standard nursing school curriculum.
Bar Code Medication Administration (BCMA) electronically verifies the 5 Rights to strengthen this process further. BCMA involves scanning barcodes on the patient’s wristband and on the medication to be delivered. The scanner interfaces with software that produces warnings or approvals (Shah et al., 2016). Barcoding doesn’t eliminate errors completely, and therefore does not replace checking the 5 Rights. The following is an example of one such error.
A nurse drew up a medication for a patient in another room and mistakenly administered the medication to [another] patient. The [nurse] scanned each medication; however, the nurse went into the wrong room, scanned the patient’s bar code, and did not check the screen prior to giving medication to the patient. The screen did verify that it was the wrong patient. The patient received three incorrect medications (Pennsylvania Patient Safety Authority, 2008, p. 124).
In this case, verifying patient identification, along with bringing the computer into the room to view the screen, would have prevented this error.
Independent double-checks include two people reviewing the medication process separately. By keeping their reviews separate, the risk of confirmation bias is reduced. Confirmation bias occurs when the first person checking the medication inadvertently influences the double-checker. When done correctly, up to 95 percent of errors can be detected using independent double-checks (Institute for Safe Medication Practices, 2019).
Labeling and Tracing IV lines involves labeling IV lines both above the pump and above the injection port at the patient end. Manually tracing lines is done at infusion set-up and involves tracing from the infusion source to the pump, and then to the source of entry into the patient, before the medication is connected or administered. It can also be done at the beginning of each shift and/or handoff (Institute for Safe Medication Practices, 2018).
Electronic order entry refers to any computerized system for ordering medications, which ensures complete and legible orders. Standardized order sets for patient-specific diagnoses guide best practice in certain scenarios — for example, use of standardized order sets for treating severe hypertension in the pregnant/postpartum patient.
E-prescribing allows prescribers to send prescriptions electronically to a pharmacy. The benefits are similar to electronic order entry — namely, complete and legible orders.
Allergy alerts, drug alerts, and disease-specific contraindications are features of electronic order entry and e-prescribing systems. They offer the benefits of clinical decision support (American College of Obstetrics and Gynecologists, 2016).
Common Errors Involving Epidural Analgesia and IV Antibiotics
According to the Institute for Safe Medication Practice (2018), safety events involving epidural analgesia and IV antibiotics mix-ups during labor have similar causal factors such as look-alike IV bags, unnoticed warning labels, unutilized BCMA, and drug shortages. The following example reflects some of these concepts.
A 16-year-old woman in labor died after accidental IV administration of fentaNYL with bupivacaine instead of penicillin G.3 The L&D workflow favored collection of all supplies at the start of labor or induction. Therefore, the epidural medication had been brought into the patient’s room before it was prescribed so it was ready for anesthesia staff when needed. The bag of penicillin G was also in the room. Both infusions had been prepared in 150 mL bags, and both bags were labeled with the same orange-colored pharmacy labels. A large pink warning label, “For Epidural Use Only,” was on the front of the epidural bag, and a small pink label was on the back. However, the nurse misread the pharmacy label, and the warning labels did not catch her attention. Her perception of risk was not high, as she thought she had penicillin G in hand, not an epidural infusion.
Several weeks before the event, the hospital’s L&D unit had implemented a BCMA system. However, most of the L&D patients bypassed the admissions department, where identification (ID) bands were typically applied, and were admitted directly to the unit without an ID band. Therefore, the patient did not have an ID band on when the nurse was administering what she thought was penicillin G. Thus, the BCMA system was not used. Within minutes of infusing the fentaNYL with bupivacaine IV, the patient experienced cardiovascular collapse. Although a healthy infant was delivered by cesarean section, the medical team was unable to resuscitate the mother (Institute for Safe Medication Practices, 2018, paras. 11-12).
Epidural Safe Practice Recommendations
The following strategies may be considered to reduce the risk of mix-ups between epidural analgesia and IV antibiotics:
Require physician order entry and pharmacy verification before the medication is retrieved
Differentiate epidural bags from other IV infusions with the use of different size or shape containers, or colored overwraps
Limit handoff between nursing and Anesthesia – Anesthesia pulls the medication from the automatic dispensing cabinet immediately before administration
Employ a complete BCMA process including a patient admission process in which identification bands are applied immediately upon arrival (Institute for Safe Medication Practices, 2018)
Last, consider workflows that pose safety risks. In the example above, it was standard nursing workflow to collect all supplies at the beginning of the patient’s labor or induction. Having supplies readily available for later use or an oncoming colleague are all done with good intentions, however creates potential safety hazards that make a case for change.
Sample test questions:
Sally Smith RN is caring for two antepartum patients with a diagnosis of chronic hypertension, receiving labetalol. She removes labetalol 200 mg PO to administer to her patient Jane Montgomery. She checks the patient ID and scans the medication, ensuring she has the right drug, dose, time, route, & patient. She is then called out of the patient’s room to answer a physician phone call. She proceeds to enter her other patients room and administers the medication to the wrong patient. This is an example of a medication error at which phase?
a. Administering
b. Dispensing
c. Monitoring
2. In the example above, if Sally Smith had noted that nifedipine was loaded in the automated dispensing cabinet where labetalol should have been, this would be an example of what type of medication error?
a. Transcribing
b. Dispensing
c. Monitoring
Answers:
a. administering
b. dispensing
*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide
Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS
References
American College of Obstetricians and Gynecologists (2012, reaffirmed 2016). Improving Medication Safety. Committee Opinion No. 531. Obstet Gynecol,120, p.1-5. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/08/improving-medication-safety
Hughes, R.G., Blegen, M.A. (2008). Medication Administration Safety. In: Hughes, R.G., editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US). Chapter 37. Available from https://www.ncbi.nlm.nih.gov/books/NBK2656/
Institute for Safe Medication Practices (2019). Independent Double Checks: Worth the Effort if Used Judiciously and Properly. Retrieved from https://home.ecri.org/blogs/ismp-alerts-and-articles-library/independent-double-checks-worth-the-effort-if-used-judiciously-and-properly
Institute for Safe Medication Practices (2018). Mix-ups Between Epidural Analgesia and IV Antibiotics in Labor and Delivery Units Continue to Cause Harm. Retrieved from https://www.ismp.org/sites/default/files/attachments/2018-10/20181004.pdf
Shah, K., Lo, C., Babich, M., Tsao, N., & Bansback, N. (2016). Bar Code Medication Administration Technology: A Systematic Review of Impact on Patient Safety When Used with Computerized Prescriber Order Entry and Automated Dispensing Devices. Can J Hosp Pharm, 69(5), p. 394-402. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5085324/
Pennsylvania Patient Safety Authority (2008). Pennsylvania Patient Safety Advisory, 5(4), p.122-126. Available from http://patientsafety.pa.gov/ADVISORIES/documents/200812_122.pdf
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