Medication Administration: Please Do Not Disturb!

I recently came across an article about a nurse who committed suicide after making a medication error that killed a baby at Seattle Children’s Hospital in 2011. (Suicide After Medical Error Highlights Importance of Support for Clinicians, Rebecca Hendren for HealthLeaders Media, May 10, 2011)

Reading the story of Kimberly Hiatt, RN and the baby who died, Kaia Zautner, made my blood run cold. This type of accident could happen to any nurse during any shift. When I was a new nurse I made a medication error that kept my patient in the hospital for two extra days. I missed a Coumadin order. This blood thinning medication is used with other anticoagulants to keep the patient safe from blood clots. I will never forget the patient who was gracious in accepting my apology. I will also never forget how horrible it felt to realize that my mistake could have hurt my patient. It changed my practice.

The process of administering medications is routine, but it’s complex. The steps that are involved including reading the physician’s order, making sure the order is transcribed correctly, pulling the medication from the dispensing machine, bringing the medications to the patient’s room, verifying the patient, verifying the medications, thinking about the medication and why the patient is receiving it, and finally giving the medication. It sounds simple enough, but during any given medication administration, these other things can and do happen:

• I am interrupted in the medication room by a doctor asking a question
• I am interrupted to take a phone call from Radiology
• I am interrupted to respond to a patient alarm
• I am interrupted to take care of another patient’s chest pain
• I am interrupted to speak to a family member waiting for me at the nurses’ station
• I am interrupted to move a patient from his bed to the stretcher to go for a test
• I am interrupted to help a patient go to the bathroom

You get the idea and if you are a nurse, you feel my pain! If you are a patient, you should be concerned that the medication administration process is not protected. In 1981 the aviation industry implemented “The Sterile Cockpit Rule.” This came about after the FAA reviewed a series of accidents that were caused by flight crews who were distracted from their flying duties during critical phases of the flight (www.airlinesafety.com). If medication administration is a “critical phase” of my day’s work, then it makes sense that I not be distracted during that time.

The problem is that as nurses we feel like we have to be all things to all people all the time! Unless it’s a true emergency, I should tell the doctor who is interrupting me, “I’m sorry, this is not a good time. I will find you when I’m done.” Maybe we need “Do Not Disturb” signs on the med room doors. Some hospitals have tried an orange vest that the RN wears during meds that alerts other staff to not interrupt. That activity reduced medication errors by 47% at a California hospital (www.nursezone.com). I don’t think I want to wear an orange vest, but I would like to have my activities respected.

Safety starts with strong leadership. Hospital administration needs to provide ongoing education to all hospital staff, including physicians, regarding the seriousness of medication delivery. Nurses need to feel empowered to discourage interruptions and advocate for both their patients and themselves. We can promote patient safety through our own actions. If I make a lethal medication error, the distraction is not going to be held accountable for the tragedy–I am. The distraction is not going to have a hard time sleeping–I am. The distraction is not going to apologize to the patient or his family–I am.

Enough said.