So, You Made A Drug Error!
It's no real surprise that drug errors happen in the hospital setting. Wards are such hectic and noisy environments which bring with it many distractions!
Picture this...
You go into the treatment room to prep your medication, you are just getting the drug out the cupboard and you can hear your patient's monitor alarming. You know that someone else will deal with it so you carry on. Next thing your pager goes off and someone starts talking to you. You carry on and start drawing up your meds and then the doctor rushes in to tell you there is an emergency. Carrying on, you finish your drug prep and then give it to your patient.
Wait a minute...you have just given the wrong dose!
Is it any wonder! You had 4 distractions whilst prepping the medication!
There are of course drug errors that can happen for a number of reasons which are not due to distractions.
I have made 2 drug errors in my nursing career which should never have happened. I made my first drug error when I was 10 months NQN. It was for a patient with complex health needs who I had been looking after for several months. I knew the patient well and knew the drug chart like the back of my hand. On this particular morning I was on auto pilot and drew up all the meds and gave them. To my horror I had given one drug 4 hours early. The drug chart had been changed the previous evening. Nobody handed this over to me, but I knew it was my responsibility. In this scenario I was complacent and it taught me to always check the drug charts properly on each shift and even during your shift. Fortunately the patient came to no harm.
This incident highlights the importance of checking the drug prescription carefully for each med you are about to give. It also hightlights the importance of a detailed hand over between shifts. It is both nurses responsibibily, i.e. the nurse handing over should go through the drug chart and the nurse receiving hand over should request this.
My second drug error involved me being second checker for IVAB. We had given the drug TDS instead of BD. We were interupted whilst drawing up the medication, however this was not the cause of the error. We had both been careless and clearly not checked the frequency of the drug. We were lucky that the patient came to no harm.
I developed a passion for patient safety and in particular safe drug administration. The ward I worked on was a very busy general paediatric ward with a high turn over of patients. We had drugs at the back of the nurses station and it was not uncommon for us to prep and draw them up there. I made it my mission to improve practice and did the following -
- Moved all drugs to the treatment room
- Had a designated prescribing desk for doctors at the nurses station (although they didn't always use it!)
- A simple do not disturb sign was put on the treatment room door
- Nurses wore a red apron whilst prepping and administering drugs
- Nurses were encouraged to ignore anyone who came into the treatment room
- Displayed poster with 6Rs (I know there are now 10Rs!)
- Displayed ward performance with drug errors - this acted as a visual prompt and gave encouragement to staff when numbers reduced
The number of drug errors did reduce but it is like any other target where it would fluctuate.
As a manager I always supported staff who made drug errors and ensured they reflected on the incident. Learning was shared with the team and we definitely had a no blame culture on the ward. It is important to support and understand why and how the error happened.
My message is simple!
If you make a drug error please reflect on it and identify any learning. Make sure you are always focussed and free from distractions, don't become complacement like I did!
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