For nurses working in hospitals, administering medication is a big part of their job and it carries a lot of responsibility. On occasion, errors occur.
For Registered Nurse Anne-Julie Dudemaine, it was only months into her first job at Banff Mineral Springs Hospital that she caught a mistake on a drug protocol form that outlined exactly how much Tinzaparin (a blood thinner) to give patients.
The dosing stated 4,500 units/kg, which if administered would result in a significant overdose. The dose should have read 4,500 units.
Anne-Julie immediately questioned the dosage with hospital pharmacy staff. She believes it was likely her fresh eyes that caught the error.
“Realistically, everybody that has been on the floor long enough knows that drug. The order is always going to be 4,500 units—period. It is a very standardized unit order, so I think people always saw 4,500 and didn’t even look further, because that is the typical order,” says Anne-Julie.
Anne-Julie adds if she had weighed her patient, the large number of vials needed for an 80-kilogram patient would also have been a red flag.
The Pharmacy Lead at the hospital, Carol Vorster, says before the form was rolled out at the site it had been reviewed by many people across Covenant Health, from nurses to pharmacists to physicians. It had also been in use for a few weeks, so many nurses on the floor did not catch the mistake either.
“It was a fabulous pickup because it had been missed by so many people,“ says Carol.
Jon Popowich, Covenant Health’s Chief Quality and Privacy Officer, understands how it can happen. There has been a lot of research into how the brain functions, and those findings are being used to improve patient care and safety.
“We are pattern-making beings. Patterns are good to recognize, but we often make patterns based on biases. In this case, this new nurse likely came to it without all the predispositions and biases,“ says Jon.
Jon believes every error is an opportunity for improvement. Over the years, significant strides have been made in medication safety.
“For example, in tall man lettering, different letters are capitalized in medications with similar names so your brain visually breaks the name up. We also mark high-alert medications and we store them in appropriate locations so they can’t be easily mixed up," says Jon. “Just telling people to be more careful doesn’t work; we need many strategies to break people’s predisposition.”
Jon also stresses it is important to have a just culture in which people are supported to come forward in discussing errors, hazards and close calls. It is not about laying blame; it is about learning why something happened and how to reduce the possibility of similar incidents happening in the future.
“Someone might say Nurse X hung up the wrong IV bag, so that is why things went wrong. But I want to know why Nurse X hung up the wrong IV bag. Were they distracted? Were they interrupted? Was the bag labelled wrong? Did someone hand them the wrong bag? There is a whole long list of things," says Jon. “It would be easy for me to say if Nurse X just did a better job, this would not have happened. It is oversimplifying the complexity of error and it does not help the culture, either.”
Jon says replacing Nurse X is not the solution. "You need to ask, would anybody else in the same circumstance do the same thing? The answer is usually yes."
Both Carol and Anne-Julie welcome the opportunity to learn from their mistakes.
“We are all responsible for ensuring things are correct, that the order we receive is correct. We need to understand the drug and question. There is never a stupid question,” says Carol.
“What I really like about Banff is that I get support and they are really open to improving the care,” says Anne-Julie.
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