Two Nurse Verifications to Reduce Medication Errors

 

Nicole Leftenant

 

College of Central Florida

 

NUR4776- Informatics and Evidence-Based Clinical Judgement

 

Dr. Rolland

 

02/22/2022

 

Introduction

A workaround is something that is done to circumvent or temporarily fix perceived workflow hindrances to meet a goal or achieve it more readily (Debono et al., 2013). Workarounds in healthcare have become more common as healthcare needs arise, and the shortage of healthcare staff has only increased. Unfortunately, the workflow realities for nursing staff do not always match the standard protocols and procedures put in place by organizations. Ask any nurse, and they will tell you at least one workaround that they've had to use due to the pressure of completing obligations within a specific time frame. Whether it be stashing certain supplies away because they know they are always scarce or overriding barcode scans in electronic health records (EHR), deviating from the safety protocol can have detrimental effects on patients' safety. In 2018, electronic health record system workarounds and lack of health IT use safety were named among the top ten patient safety concerns for healthcare organizations, according to a report from the ECRI Institute (Monica, 2018). As workarounds in healthcare become more prevalent, it is imperative for nurses and their leadership to acknowledge them, discuss the reasons for deviation, and analyze safe solutions (Rushton & Stutzer, 2015). The purpose of this paper is to identify a specific workaround, examine its key components, explore evidence-based solutions to address the workaround and make recommendations for change.

The Workaround

During a busy shift, a fellow nurse on the unit came to me with a question regarding starting a new heparin drip. The nurse was concerned that the provider had ordered a bolus dose of heparin as an intravenous push before hanging the continuous infusion. I explained that providers do call for this at times depending on the patient's needs but cautioned them always to verify any order they are uncomfortable with. After that brief conversation, we both went about our days as usual. Shortly after, this same nurse came to the charge nurse and me in a panic; they had drawn up and already administered the bolus dose of heparin but realized after that the dose administered was not only incorrect but very high. There is a safety alert when administering heparin. In this charting system, if giving a heparin bolus, there is a safety alert warning for a second nurse verifying the dosing. However, nurses can bypass this safety alert, and in this scenario, it was. The workaround in this scenario is overriding a safety feature in the EHR.

Quality Measures

The data collected in relation to this workaround is data relating to the medication error and its reporting. According to the Center for Drug Evaluation and Research (https://www.fda.gov), data is collected from medication manufacturers, healthcare professionals, and consumers through a program called MedWatch. The specific data collected consists of the result of the adverse event (i.e., death, serious injury, etc.) and the date of the event. Additionally, they may request relevant lab results, patient history, medication(s) involved, including lot number and expiration, the dose of drugs, the reason for treatment, and the term of therapy. Multiple databases collect data and report adverse events related to medication errors. The Institute for Safe Medication Practices (ISMP) is a nonprofit organization dedicated to the prevention of medication errors (http://www.ismp.org). The Agency for Healthcare Research and Quality (http://www.ahrq.gov) also uses multiple data sources to collect adverse and sentinel events relating to medication errors. The FDA Adverse Event Reporting System (FAERS) contains information on adverse events and medication errors reports submitted to the FDA (https://open.fda.gov/data/faers).

Policy

The clinical policy affected most in this scenario was ”verifying the eight rights of safe medication administration” (Policy and Procedure, 2021). The eight rights of medication administration consist of the right patient, right drug, right dose, right route, right time, right documentation, right reason, right response  (Policy and Procedure, 2021). If the nurse in the scenario had followed the step of verifying the right dose and documentation, the situation could have had a different outcome. Verifying the right dose prior to administration could have alerted the nurse that the amount she drew in the syringe was incorrect, directly affecting the clinical policy. Verifying dose checks for correct conversion of units, wrong dosage, and incorrect concentration or substance. Bypassing the safety alert to have a second nurse verify the dose led to incomplete documentation; therefore, confirming the right documentation was a step that the nurse skipped which directly affected the clinical policy. Verifying correct documentation ensures that if a cosigner is needed for a medication administration, their sign-off is appropriately documented as a second verification.

Stakeholders and Systems

Numerous stakeholders are responsible for ensuring patient safety. They include healthcare professionals, patients, families, and even healthcare leaders. The workaround in this scenario directly affected the patient and indirectly affected their family. Patients and families who have been victims of medication errors have reported long-term psychological issues, even nightmares after the event (Ottosen et al., 2018). The nurse involved was also directly affected, and the medication error could have had a detrimental effect on their emotional state and mental health. The nursing department involved and the hospital itself were indirectly affected due to the adverse event due to the potential for decreased patient satisfaction scores due to growing lack of trust in the healthcare system. The system put in place to prevent medication errors was also indirectly affected by bypassing safety features embedded in the system to prevent such adverse events from occurring.

Root Cause

A fishbone diagram was used to determine the root cause of this workaround extensively. A fishbone diagram is used to visualize a cause and effect. It is a structured approach with the head of the fish being labeled as the problem and the body or "smaller bones" being marked with the contributing factors. I determined the root cause to be the nurse bypassing the "hard stop" safety alert in the EHR, bypassing a second nurse verification. The fishbone model used helped me determine the factors contributing to the medication error. The environment was considered, the people involved, the system used, and the equipment used. Each category had pertinent facts and details that could have led to the workaround. The environment was chaotic, multiple call lights ringing, and an increase in nurse-patient ratio from 1:6 to 1:7 could have led the nurse to feel pressured. The people involved consisted of the nurse, the provider, the pharmacist, the nursing staff for support, the patient, and the family. The equipment was functioning to its full potential without any flaws. The EHR system alerted the nurse with a hard stop safety alert, warning that it was a high-risk medication, and the second nurse should initiate a double nurse verification. The workaround occurred when the nurse bypassed the hard stop feature of this system and administered the medication to the patient.

Solutions

A solution to the workaround would be to implement and maintain the policy to have two nurse verification (double-checks) for high alert medications such as heparin, insulin, blood, etc. Two nurse verifications allow the opportunity for mistakes, both minor and significant, to be caught before any harm is done to the patient. In a direct observational study completed by  Westbrook et al. (2020), when a second nurse double-checked medications, the odds of a medication administration error were significantly lower. For double-checked drugs, medication errors were 27/100, and when not double-checked 37/100 (Westbrook et al., 2020). In a randomized control trial conducted by Modic et al. (2016), nurses who used second nurse verification for insulin administration had error rates of 27.6% versus 33.3% of those who did not use double nurse verification. The statistical data from the research presented supports my solution to work around by verifying that medication errors do decrease, although not tremendously, with two nurse verifications in place, improving patient safety.

Peer-Reviewed Research
a.     Article One:
Author(s), Title, Year	Westbrook, J. I., Li, L., Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T., Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L., Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., & White, L. (2020). Associations between double-checking and medication administration errors: a direct observational study of pediatric inpatients. BMJ Quality & Safety, 30(4), 320–330. https://doi.org/10.1136/bmjqs-2020-011473
Research Design	Direct observational study
Level of Evidence (High, Moderate, Low)	moderate
Participants, Sample Size	1523 patients, 298 nurses in a 340-bed tertiary hospital
Intervention Tested  – Must match the proposed solution	Nurse double checks (two nurse verification)
Outcomes Measured	Medication error rates
Results/Findings  (must include stats, p-values)	·          The MAE rate for medications where double-checking was mandatory was 71·6/100 administrations and 34·7/100 administrations among medications where double-checking was optional ·          When double-checking was optional (n=1577), and  applied (n=416), we found there was a significantly lower odds of the occurrence of an MAE (OR:0·71 (0·54–0·95)) and MAE severity (OR: 0·75 (0·57–0·99) ·          . For double-checked administrations the error rate was 29/100 and for those not double-checked, 37/100 administrations ·          Results were considered significant at a value of p=0·05
b.    Article Two
Author(s), Title, Year	Modic, M. B., Albert, N. M., Sun, Z., Bena, J. F., Yager, C., Cary, T., Corniello, A., Kaser, N., Simon, J., Skowronsky, C., & Kissinger, B. (2016). Does an Insulin Double-Checking Procedure Improve Patient Safety? JONA: The Journal of Nursing Administration, 46(3), 154–160. https://doi.org/10.1097/nna.0000000000000314
Research Design	Randomized control trial
Level of Evidence (High, Moderate, Low)	moderate
Participants, Sample Size	1400 bed quaternary care medical center On 3 medical units and 2 surgical units 266 patients
Intervention Tested  – Must match the proposed solution	Nurse double checks (two nurse verifications)
Outcomes Measured	Decreased medication errors
Results/Findings (must include stats, p-values)	·         Of insulin preparation opportunities, 3473 of 5238 (66.3%) were without errors. ·         The nonerror rate was higher among intervention (1419 preparation opportunities [71.2%]) than usual care (2054 preparation periods [63.3%]; P < .001) patients ·          The double-checking group had fewer wrong time errors than did theusualcaregroup,551(27.6%)versus1079(33.3%), P < .001. ·         Of nonerrors, wrong time and omission errors (basal, prandial, and correctional insulin doses) occurred most often at 1.9% and were less frequent in patients who received double-checking (n = 16 [0.80%]) compared with usual care (n = 84; 2.6%; P < .001).

Barriers and Change

Barriers that may be evident to the proposed solution of two nurse verifications would be lack of time and ability to locate available nursing staff (Westbrook et al., 2020). As stated earlier, with the rise in healthcare needs of patients, and nursing shortages, it may be difficult for already busy nursing staff to make time to double-check one another. In addition, nurses are expected to be analytical problem solvers that can juggle multiple tasks at once. However, adding another roadblock to a daily intervention may cause barriers and resistance to change. To overcome barriers, Kotter and Cohen’s Model of Change should be used to introduce the change to nursing staff (Melnyk, B.M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4^th edition)).  According to Kotter and Cohen, there are eight steps for successful change. Step one is creating a sense of urgency for the difference. This could be done by showing error rates and the need for change. Step two build the guiding team makes the team feel like they can be the change. Step three gets the vision right, ensures all members are on board, and knows the end goal and vision to increase patient safety. Step four communicates for "buy-in" during this step, people see and accept the change as worthwhile. Step five empower action and remove barriers; people begin to change. Step six creates short-term wins. When change begins with less resistance, continue to encourage the team and reward them. Step seven do not let up; continue to empower the difference, and improve patient safety. Step eight make change stick, encourage the double nurse checks, show the team the improvements and changes. Following all eight steps can promote change and decrease barriers and resistance.

Summary and Conclusion

In summary, this paper explored a workaround in which a nurse bypassed a safety feature in a system to administer a medication quickly, not realizing it was the incorrect dose leading to a medication error and adverse event. This workaround put patient safety at risk and had detrimental effects on multiple stakeholders. If the nurse had used a second nurse verification per system protocol, patient safety would not have been put at risk, and the error could have been prevented. A solution to this workaround is making two nurse verifications (double checks) standard protocol for high-risk medications for all nursing staff. In conclusion, nursing staff is at the frontlines of providing safe, quality patient care. Taking time to ensure that medications are being administered safely with second nurse double-checking is a simple way to ensure patients receive the safest care possible. For future research and practice, a pilot study should be completed to test the effectiveness of second nurse verifications to reduce medication errors.

 

 

References

1. (2018, March 15). Health IT Use, Workarounds Among Top 10 Patient Safety Concerns. EHRIntelligence. https://ehrintelligence.com/news/health-it-use-workarounds-among-top-10-patient-safety-concerns

Melnyk, B., & Fineout-Overholt, E. (2018). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (4th ed.). LWW.

Modic, M. B., Albert, N. M., Sun, Z., Bena, J. F., Yager, C., Cary, T., Corniello, A., Kaser, N., Simon, J., Skowronsky, C., & Kissinger, B. (2016). Does an Insulin Double-Checking Procedure Improve Patient Safety? JONA: The Journal of Nursing Administration, 46(3), 154–160. https://doi.org/10.1097/nna.0000000000000314

Ottosen, M. J., Sedlock, E. W., Aigbe, A. O., Bell, S. K., Gallagher, T. H., & Thomas, E. J. (2018). Long-Term Impacts Faced by Patients and Families After Harmful Healthcare Events. Journal of Patient Safety, 17(8), e1145–e1151. https://doi.org/10.1097/pts.0000000000000451

Policy and Procedure. (2021, July). Methodisthospitals.Org. https://web.methodisthospitals.org/On-LineOrientation/StudentNursing/Docs/NSI-MED_03.pdf

Rasool, M. F., Rehman, A. U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Ahmad Hassali, M. A., & Hayat, K. (2020). Risk Factors Associated With Medication Errors Among Patients Suffering From Chronic Disorders. Frontiers in Public Health, 8. https://doi.org/10.3389/fpubh.2020.531038

Rushton, C. H., & Stutzer, K. (2015). Ethical Implications of Workarounds in Critical Care. AACN Advanced Critical Care, 26(4), 372–375. https://doi.org/10.4037/nci.0000000000000107

Tucker, A. L., Zheng, S., Gardner, J. W., & Bohn, R. E. (2019). When do workarounds help or hurt patient outcomes? The moderating role of operational failures. Journal of Operations Management, 66(1–2), 67–90. https://doi.org/10.1002/joom.1015

Westbrook, J. I., Li, L., Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T., Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L., Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., & White, L. (2020). Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. BMJ Quality & Safety, 30(4), 320–330. https://doi.org/10.1136/bmjqs-2020-011473

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