Consider the following scenario: It is a typical busy morning on the ward. The unit is full to capacity. One of the nurses called in sick prior to the beginning of the shift, and thus far no replacement has been found. The other nurses have had to pick up the slack, increasing their patient load by two patients each. They are unhappy about this turn of events and are madly scrambling to meet the needs of their patients. They are off to a slower start than normal due to having to revise their patient care plans. Physicians are arriving to make rounds, writing numerous new orders and asking questions. Call bells are ringing, phones are ringing and breakfast trays will be arriving imminently. Patients must be toileted and prepared for breakfast, and morning meds are due.
An inexperienced nurse is preparing meds for her patients. She reads the medication administration record and notes that one of her patients is to receive rapid-acting insulin. Hospital policy states that she is to check the patient’s chart to ensure that the dose on the MAR matches the most recent physician’s order. In addition, the insulin dose is to be checked with another licensed staff member.
The nurse is feeling stressed — two of her patients have requested pain medication, one is using a bed pan, and another is supposed to be going for a CT scan and requires a Barium prep which she has not yet given. The nurse draws up the insulin and looks for another nurse to check and co-sign the insulin with her. After five minutes of searching, she cannot find another nurse who is not engaged with another patient. And the nursing manager is in a meeting.
The nurse gives her patient the insulin she has drawn up without having it checked. She gives an incorrect dose and does not realize until the patient experiences a severe and near-fatal drop in blood glucose. Who is to blame?
In the scenario above, several factors influenced the nurse in making the decision to take a deadly shortcut. Although ultimately the nurse was responsible for giving the insulin without having the dose confirmed by a colleague, some of the other events that influenced this decision include:
– The shortage of nurses, which increased the staff’s stress level and likely caused them to feel rushed, as well as disrupting the normal routine.
– The absence of the nurse manager, who might have decided to stay on the unit to lend assistance and support given the staffing shortage.
– The high nurse-patient ratio, which led to a situation of too many demands and too little time.
– The inexperience of the nurse, which may have influenced the nurse’s time management and decision-making skills, as well as her judgment.
– The presence of a sound procedure for a common nursing practice, but no plan in place to ensure that the procedure can be followed in “real life.”
Safe practices regarding medication administration cannot be overemphasized. However, nurses and managers must work together to identify dangerous practices and find solutions to manage identified problems. A culture of blame must be avoided so that nurses feel able to identify near-miss experiences, as well as actual errors, without fear of backlash. When nurses are involved in creating solutions to problems, they are far more likely to adhere to expected practice and less likely to take shortcuts. A unit-based med safety team can be a great place to start to address medication administration issues.