IT COULD HAPPEN TO YOU

IT COULD HAPPEN TO YOU

Avoid distraction, stay focused

By Sue Jones
CQI COORDINATOR
Martine Hugel, R.N.

Martine Hugel, R.N., carefully calibrates an IV machine.

Possible scenario:Patient A has orders for Levophed IV. The patient’s nurse removes the Levophed bag from the refrigerator and brings it into the patient’s room.

As the nurse enters Patient A’s room, she notices that her other patient in that room, Patient B, is in respiratory distress. She puts down the IV bag to assist Patient B. With her attention focused on Patient B, the nurse picks up the IV bag and hangs it for that patient, not Patient A. Within minutes, Patient B becomes hypotensive. In analyzing the patient’s unexpected reaction, the nurse notices the error and stops the medication. Emergency actions reverse the impact on Patient B, who received the wrong medication.

How could such an error occur – and how can we prevent it?

  • Health care providers can be distracted by countless activities, conversations or questions while administering medications, or while performing patient care responsibilities. After the distraction it can be difficult to remember where they left off. Unless the health care provider starts that action over again from the beginning, there are multiple opportunities for error.
  • Health care providers who take care of patients for long periods of time may become confident that they don’t need to check their patient’s armband every time. However, checking the armband against the label on the IV bag assures the Five Rights: right patient, right drug, right route, right dose and right time.