Question

A retired 81-year old man with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospitalization, he was transferred to a skilled nursing unit to complete antibiotic therapy. Cancer chemotherapy was scheduled to begin after discharge. Three days after transfer to the skilled nursing unit, the patient complained of nausea. Intravenous ondansetron (Zofran) was ordered. Approximately one hour after the first dose of ondansetron, he was found unresponsive and in respiratory distress. Stat labs were ordered, and his blood glucose was 23 mg/dL. The patient had no history of diabetes or hypoglycemia. He was given glucagon and transferred to the intensive care unit. Laboratory studies showed an insulin level of greater than 1500 micro-units/mL (upper end of the reference range: 17 micro-units/mL). Intravenous glucose and glucagon were continued, and his blood glucose stayed in the low 40 mg/dL range for several days. Ultimately, he was discharged without any permanent disability from the event, but he was in a weakened state and his chemotherapy was delayed. The incident led to an internal review of the case. In this skilled nursing unit, many of the nurses remove medications from the Pyxis machine (an automated dispensing device) and insulin from the refrigerator and place them in portable medication carts that are then taken to the bedside. The nurse who was caring for the patient the night of the first ondansetron dose worked infrequently and had an especially heavy workload that evening (she was caring for nine patients on her shift). When her portable medication cart was inspected, ondansetron and insulin vials were found to be next to each other. It was presumed that she mistakenly administered insulin instead of ondansetron. What factors (human, work load, and environment) contributed to this error? What recommendations can you make to prevent this type of error in the future?

Answer 1

Medication errors are among the most common health threatening mistakes that affect patient care. Such mistakes are considered as a global problem which increases mortality rates, length of hospital stay, and related costs.

Giving medicine is probably one of the most critical duties of nurses since the resulting errors may have unintended, serious consequences for the patient.

The causes for medication errors are divided into three categories

1. personal,
2. contextual and
3. knowledge-based factors,

1.personal factors include, stress, tiredness, confusion, the physician prescription, errors of orders implementation, inadequate attention to details, lack of job-satisfaction, unpleasant workplace, decreased sense of commitment and career conscience and so on.

2.contextual factors are the lack of competent and skilled staffs, heavy overtime work, long work days, a crowded ward, necessity of intensive cares, and etc.

3.knowledge-based causes include, inadequate pharmaceutical knowledge and experience, no awareness about patients’ and drug mathematical calculations.

Patient safety is one of the foundations of nursing. Nursing errors may cause patient harm and can be devastating for the nurse. While system and equipment failures do contribute to errors, we know that human factors are involved, including some factors that are uncontrollable and part of human nature.

Although, a severe shortage in the nursing workforce in hospitals may increase the probability of medication errors occurrence,

Heavy workload of hospital nurses is a major problem for the American health care system. Nurses are experiencing higher workloads than ever before due to four main reasons:

(1) increased demand for nurses,

(2) inadequate supply of nurses,

(3) reduced staffing and increased overtime, and

(4) reduction in patient length of stay.

The demand for nurses is increasing as a result of population aging, the supply of nurses is not adequate to meet the current demand, and the shortage is projected to grow more severe as future demand increases and nursing schools are not able to keep up with the increasing educational demand. When a nursing shortage occurs, the workload increases for those who remain on the job.hospitals reduced their nursing staffs and implemented mandatory overtime policies to meet unexpectedly high demands, which significantly increased nursing workloads. Increasing cost pressure forced health care organizations to reduce patient length of stay. As a result, hospital nurses today take care of patients who are sicker than in the past; therefore, their work is more intensive.

heavy nursing workload adversely affects patient safety.Furthermore, it negatively affects nursing job satisfaction and, as a result, contributes to high turnover and the nursing shortage.

In addition to the higher patient acuity, work system factors and expectations also contribute to the nurses’ workload: nurses are expected to perform nonprofessional tasks such as delivering and retrieving food trays; housekeeping duties; transporting patients; and ordering, coordinating, or performing ancillary services.

Concepts and Models of Nursing Workload

Nursing workload measures can be categorized into four levels:

(1) unit level,

(2) job level,

(3) patient level, and

(4) situation level.

The situation- and patient-level workloads are embedded in the job-level workload, and the job-level workload is embedded in the unit-level workload. In a clinical unit, for example, numerous nursing tasks need to be performed by a group of nurses during a specific shift (unit-level workload). The type and amount of workload of nurses is partly determined by the type of unit and specialty (e.g., intensive care unit [ICU] nurse versus general floor nurse), which is the job-level workload. When performing their job, nurses encounter various situations and patients, which are determinants of the situation- and patient-level workloads.

Workload at the Unit Level

The most commonly used unit-level workload measure is the nurse-patient ratio. The nurse-patient ratio can be used to compare units and their patient outcomes in relation to nursing staffing. High nursing workloads at the unit level have a negative impact on patient outcomes.These studies’ suggestions regarding improving patient care are limited to increasing the number of nurses in a unit or decreasing the number of patients assigned to each nurse. However, it may not be possible to follow these suggestions due to costs and the nursing shortage.

Workload at the Job Level

According to this conceptualization, the level of workload depends on the type of nursing job or specialty (ICU nurse versus operating room nurse). For instance, Schaufeli and LeBlanc used a job-level measure of workload to investigate the impact of workload on burnout and performance among ICU nurses. Previous research linked job-level workload (a working condition) to various nursing outcomes, such as stress and job dissatisfaction. Workload measures at the job level are appropriate to use when comparing workload levels of nurses with different specialties or job titles (ICU nurses versus ward nurses).

Workload at the Patient Level

This conceptualization assumes that the main determinant of nursing workload is the clinical condition of the patient. Several patient-level workload measures have been developed based on the therapeutic variables related to the patient’s condition (e.g., Therapeutic Intervention Scoring System) and have been extensively discussed in the nursing literature. However, recent studies show that factors other than the patient’s clinical condition (e.g., ineffective communication, supplies not well-stocked) may significantly affect nursing workload. As with the previous two workload measures, patient-level workload measures have not been designed to measure the impact of these contextual factors on nursing workload.

Situation-Level Workload

To remedy the shortcomings of the three levels of measures explained above and complement them, we have suggested using another way to conceptualize and measure nursing workload based on the existing literature on workload in human factors engineering: situation-level workload. In addition to the number of patients assigned to a nurse and the patient’s clinical condition, situation-level workload can explain the workload experienced by a nurse due to the design of the health care microsystem.For example, sometimes several members of the same family may call a nurse separately and ask very similar questions regarding the same patient’s condition. Answering all these different calls and repeating the same information about the patient’s status to different members of the family is a performance obstacle that significantly increases the (situation-level) workload of nurse.

Recommendations to prevent this medication error in the future:

The protective measures against medication errors are related with the preparation and administration of medications, the dosing calculations skills of nurses, the nursing education, the oral medication orders, the interdisciplinary collaboration, the manager nurses and changes in health systems’ issues relevant with medication management.

reduce working pressure by increasing the number of staff proportional to the number and condition of patients

Education and improve nurses’ knowledge about drugs and proper medicine prescribing and medication with principles and techniques

Availability of the necessary information about drugs, side effects and interactions in the wards

Using infusion pumps in wards in order to avoid rapid infusion of dangerous drugs

Improve the working environment such as lighting, temperature, humidity, noise, controlling the number of patients, the movement of the patient accompanying

Inform and educate nurses about new drugs

Choosing nurses for different wards according to their interests

Paying attention to medication error reports as an opportunity to learn in order to prevent their recurrence