Avoid errors with these tools
Want to avoid medication errors? Don’t rely on your memory, perform split-second calculations, or make assumptions, advises Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency/ trauma services for University of California-Irvine Medical Center in Orange. Instead, use tools as aids to determine and double-check dosages, she urges.
Here are several tools to add to your ED’s arsenal:
• Dosage charts.
Standardized charts with medication concentrations and weight dosages might prevent errors from occurring, says Bradley. "It will also save the nurse the time of verifying the calculation and double-checking for accuracy," she adds.
Dosage charts that are specific to adult or pediatric patients are used at University of California Irvine Medical Center’s ED. "These are particularly helpful when we dose the patient based on weight requirements, such as with dopamine," says Bradley. (See protocol for Rapid-Sequence Induction in the Adult ED Patient with Suspected Head Injury, right; Conscious Sedation Quick Reference Dosing Chart, pp. 140-141; and charts for norepinephrine and nitroglycerin infusion rates, inserted in this issue.)
Dosing patients based on weight might predispose a nurse to make a medication error, says Bradley. "These errors most often occur in the calculation of the drug dosage," she says. "For instance, if a drug is to be ordered for micrograms per kilogram per minute, calculating the drug dosage based on the concentration and the patient’s weight may produce error."
In emergencies, dosage charts are essential, so the appropriate dose of medication is given every time, notes Bradley. "A good example of this is the Broselow Rainbow tape in which emergency pediatric drugs are listed by patient weight," she adds. (For more information on color-coded dosage equipment, see ED Nursing, September 1999, p. 139.)
For example, the Broselow tape might indicate that a medication such as Diazepam is given at a dose of 1-3 mg for a 10 kg child, which eliminates the opportunity of calculation errors, says Bradley.
"The potential for error in a child is always high because calculations are required," she adds. "A single shift in the decimal point during the calculation could result in a serious error."
Dangerous interactions listed
• Compatibility charts for intravenous (IV) drug administration.
Charts posted at the University of California-Irvine’s ED instruct nurses in compatibility of medications given to patients on IVs. For example, for a patient that is receiving IV Dilantin, nurses are instructed to mix the drug with a normal saline solution rather than a dextrose solution, Bradley explains. "In many situations, it will also list the quantity of solution required," she says.
Compatibility charts alert you to dangerous drug interactions, says Bradley. "Some drugs may precipitate or may become inactivated when mixed with other drugs," she adds. "In having a compatibility chart as a guide, you know if it’s acceptable to mix all administered drugs through a single line, or if it is necessary to start a secondary line."
• Standards of practice.
At University of California-Irvine, standards of practice are used for the dosing of medications at triage. "Dosing standards are very explicit as to contraindications, and range of dose administration is based on age and weight," says Bradley.
For example, the ED’s dosing protocol at triage includes the following:
— Tylenol 15 mg/kg for temperatures > 38.5° C (101° F);
— Motrin 10 mg/kg for children over 3 years of age.
Administering antipyretics at triage is an essential practice, Bradley stresses. "It is valuable to prevent the consequences of fever such as febrile seizures, to provide for patient comfort, and to see if the antipyretic is effective for the relief of fever," she adds.
• Protocols.
For complex administrations such as t-PA, not having to depend on memory is key, says Robert Wears, MD, MS, FACEP, professor in the department of emergency medicine at the University of Florida College of Medi-cine in Jacksonville. "Not only do you ensure correct dosage of the medication, but it also helps to be sure the other parts of the protocol go correctly," he adds.
Here are some ways to maximize the benefits of protocols:
• Avoid following protocols mindlessly.
Catch yourself when you begin to follow a protocol without careful thought, says Wears. "During the [1982] Air Florida 90 crash, which was due to icing, the cockpit voice recorder documented the pilots going through the checklist and saying: "De-icers off? — Check, de-icers off. " It was obviously a mistake, but was by far the standard response," he notes.
• Simplify administration protocols.
When possible, use protocols that are less complicated, Wears recommends. "The new reteplase regimen with simpler bolus doses has about a 50% lower medication error rate than the old complicated t-PA dosing regimens," he notes.
• Avoid cumbersome instructions.
"If you can’t both follow a protocol and get the work done in a reasonable time, you commonly deviate from them," Wears says. Then if the deviation is associated with an error, the institution can blame the individual for not following the protocol, he warns.
• Monitor deviations.
Tracking deviations in your ED protocols is the best way to improve them, Wears advises. "This is not to punish people, but to understand why reasonable people feel it necessary to deviate," explains Wears.
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