Issue link: https://digital.copcomm.com/i/1130164
Working Nurse l WorkingNurse.com 19 June 10–July 15, 2019 The Fatal Cost of Distraction H ow many medication errors are also predictable surprises? I don't know of any way to know for sure, but every time I hear about a new incident, I wonder. A sobering recent example was the February 2019 indictment of Tennessee RN RaDonda Vaught, a former nurse at Vanderbilt University Medical Center in Nashville. She was charged with reckless homicide and abuse of an impaired adult in the fatal medication error that killed patient Charlene Murphey in December 2017. Vaught admitted that she was distracted talking with a colleague when she overrode the automated medication dispensing system and administered the powerful surgical anesthetic vecuronium rather than the prescribed Versed, an anti-anxiety medication. The 75-year-old Murphey died hours later. The exact circumstances will probably be argued at length in court — Vaught has pleaded not guilty to the charges — but incidents like this are a reminder that taking even occasional shortcuts with medica- tion administration can be deadly. Ask Yourself Honestly I f you ever find yourself tempted to bend a rule while under pressure at work, you're probably not the only one. Unfortunately, because we don't usually talk about it unless someone gets in trouble (and sometimes not even then), we may have no idea just how many short- cuts the other nurses around us may be taking every day. We need to have open and honest conversations with each other and our leaders before we develop bad habits that put our patients at risk — and before something goes terribly wrong. It's time to break the code of silence that paralyzed me and my supervisor that day years ago. Ask yourself honestly how many of these common shortcuts you've taken: ◗ Relying on memory from earlier in the day or a previous shift rather than going through the proper steps again. ◗ Stopping in the middle of the process to answer an alarm and then picking up where you think you left off rather than starting over. ◗ Trusting that the pharmacy sent the right dose/medication with- out double-checking. ◗ Administering medication at what you know is the wrong time and writing it off as "close enough" or your only opportunity. ◗ Using "patient refused" or "patient sleeping" as an excuse for not following protocol. ◗ Overriding the automated dispensing system rather than taking steps to correct a problem such as an unreadable barcode. Often, these bad habits reflect problems beyond the individual nurse's ability to solve. Workflows might need to be adapted to better fit with current equipment. Buggy barcode scanners need to be replaced. The hospital might need to take steps to reduce distracting noise, minimize alarm fatigue or, most importantly, hire more staff so nurses have time to do their jobs properly. None of those things is likely to happen if we don't speak up. As nurs- es, we're expected to be patient advocates, but to do that, we must also advocate for ourselves and ensure that our colleagues and leaders respect our concerns and our limitations. WN BETH BOYNTON, RN, M.S., is an organizational development consultant specializing in communication, collaboration and culture, and the author of Medical Improv: A New Way to Improve Communication. She is currently working on an ebook series. Reach her at beth@bethboynton.com.