• Cases & Commentaries
  • Published November 2005

Infused, Not Ingested

The Case

A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rather than giving the Gastrografin solution orally via a nasogastric tube (the appropriate route), the nurse took the bottle of contrast, mixed it in a 250-cc bag of normal saline, and infused it intravenously.

When the patient arrived for the study, the radiology technician asked the nurse whether the patient received the ''oral'' contrast solution. The nurse responded, ''Yes,'' and quickly removed and discarded the IV bag. Suspecting an error, the technician contacted the radiologist, and they discovered an IV bag marked ''contrast'' in the trash after the nurse departed from the radiology suite.

The nurse was subsequently approached about the error and failed to disclose the actual events. The physician caring for the patient did not inform the family of the error until the following morning, stating he wasn't certain of the consequence of receiving oral contrast intravenously. As it turned out, the patient developed acute renal failure, but it resolved without any significant sequelae.

Following the event, the nurse was fired. The nurse reported that his primary role involved non-ICU care, and this was the first time he administered contrast or transported a patient for a radiology study. He ''floated'' to work in the ICU that particular day due to staffing issues. The hospital responded by marking all oral contrast bottles ''PO ONLY—NOT IV.''

The Commentary

Medication errors by nurses occur frequently, largely due to their bedside role in patient care and the sheer volume of medications they administer.(1) A 2002 study of 36 institutions reported that medication errors occurred in 1 out of every 5 doses in the typical hospital or skilled nursing facility.(2) Nurses also prevent many medication errors, again due to their bedside role and knowledge about medication administration.(3) Although this case offers an opportunity for discussion of communication breakdown, handoffs, unclear labeling, professional competence, and professional ethics, this commentary will focus on two unique issues that it raises: (i) the staffing practice known as ''floating'' and the underlying challenge of assuring staff competence, and (ii) the nurse's failure to report or acknowledge the error.

Staffing, Floating, and Competency

The relationship between nurse staffing and patient safety has been well documented during the last 10 years.(4,5) Most staffing studies focus on the nursing workload (nurse-to-patient ratios) or the effects of fatigue related to working overtime. Less research exists on the relationship between scheduling issues or competency and patient safety. Hospitals typically hire a core complement of nurses for each patient care unit, but staffing requirements for these units can fluctuate widely due to patient census, patient acuity, and staff vacancies. To optimize staffing flexibility and accommodate increased staffing requirements, hospitals use a combination of scheduling strategies to ''flex'' up. For instance, hospitals may hire temporary staff from an agency, use an ''in-house registry,'' or move nurses from unit to unit as the census shifts.

In this case, the hospital utilized one of these strategies, by ''floating'' a nurse from a regularly assigned area to an area of need. The practice of floating is not new, nor are the problems associated with it. For example, one study reported that unfamiliarity with a unit contributes to an increased number of medication errors.(6) All registered nurses are expected to have a foundational scope of practice. Additional knowledge, skills, and abilities can be categorized as ''competencies.'' Practicing as a nurse on a general medical-surgical unit requires certain competencies. Since critical care units have an entirely different level of acuity, their practice competencies are different from those in general or post-acute units. In this case, a nurse with primary roles in non-critical care—by his own admission not qualified to work in critical care—floated to a unit where he lacked necessary competencies.

Each staff person assigned to an area, temporarily or permanently, is expected to have the required competencies to practice safely in that area. It is the responsibility of hospital and nursing management to assess staff competence and assure that only those with appropriate preparation work in those areas. In this case, the institution and/or managers may well have failed in that responsibility.

While floating is a universal practice, little literature exists to support a remedy to the challenges it creates. Some floating is inevitable, and many of the concerns regarding competencies can be answered if the floating nurse is instructed and empowered to ask questions or even assigned a specific experienced nurse to use as a resource. In this case, it is not clear whether such a person had been assigned, or whether the culture was one in which staff were encouraged to acknowledge their limitations. In institutions that frequently use floating as a staffing solution, one might prioritize not only hiring an adequate supply of nurses for each clinical area but also implementing strong orientation and competency requirements when floating is required. If nurses are asked to float to an area in which they are unqualified and their request for an orientation and/or resource person is denied, it is their legal and ethical duty to refuse to accept the new assignment. They may suffer the consequence of a reprimand, or termination, which is a better outcome than risking their license or a patient's life with an error. In practice, this tension is exactly what leads to cases such as the one presented here.

Reporting or Acknowledging an Error

In this case, the nurse first failed to acknowledge an error when the technician asked about the ''oral'' contrast. Workers' reluctance to report errors may stem from a punitive work environment and the stigma that error has attached to it.(7) National licensing bodies have supported research to distinguish between system causes and individual practitioner responsibility for errors. One study described failures in ''practice responsibility'' as contributors to error.(8) This nurse ultimately acknowledged that he had never before administered contrast, nor had he been responsible for a patient undergoing a radiological procedure off a unit. In the proposed taxonomy, his lack of clinical knowledge specific to the details of the care could be classified as ''inappropriate judgment,'' specifically, inadequate clinical judgment.(8) The Code of Ethics for Nurses (9) requires a primary commitment of the nurse to the patient, and truth telling is foundational.

In an effort to balance error, blame, and discipline, the principles of a ''just culture'' have emerged.(10) A just culture strives to balance communication and deterrence. That is, when an error occurs, can an employee safely come forward so that the organization can learn from the event? Moreover, are human errors distinguished from reckless conduct or rule violations, and are the consequences different?(10) Because the nurse tried to conceal and not address the error, he moved beyond human error (lack of judgment leading to the error) to negligent conduct.(10) A prudent nurse would have been expected to notify a superior that he was unfamiliar with the procedure. A prudent nurse also would have acknowledged the error when first confronted. When he was questioned again and failed to disclose the actual events, the nurse was exhibiting behavior that demanded discipline. According to the just culture classification, he was likely culpable of an intentional rule violation.(10) Although human error is inevitable and often defensible, it was the failure to disclose the facts when confronted that constituted an indefensible breach of the ethical obligation.(9)

The ideal response would have included (i) an evaluation of the event, using a root cause analysis (RCA), (ii) disclosure to the patient and family with an apology, and (iii) in the course of the RCA, determination of how a nurse without proper orientation or supervision ended up with those responsibilities. Unfortunately, I believe that this nurse should be terminated, not for committing the error, but for failing to come forward to accept responsibility. Nurses, doctors, and pharmacists all want to do the right thing when it comes to patient care. Importantly, if the situation here involved another provider (a physician, for example) rather than a nurse, the same principles should apply.

Dismissing this case as that of a flawed nurse would be insufficient. The case presentation did not disclose any information about the nurse's age, years of experience, ethnicity, or primary language. A recent graduate may feel less comfortable advocating for the additional preparation that should precede assignment to an unfamiliar area. With some foreign-born nurses, cultural practices may make it very difficult to express concerns or challenge an administrative order. Nurses with English as a second language may have additional difficulties articulating their concerns or understanding information communicated verbally. That he did not object to a critical care assignment or seek support should raise questions regarding the overall environment for safety, which may not have encouraged, or even actively discouraged, seeking support or reporting errors. The hospital leadership and the lack of a culture of safety must still be evaluated as a potential root cause of the entire event or, at the least, the nurse's initial response to the error.

Hospital Leadership and a Safety Culture

Although the case, as submitted, does not include specific information on the leadership or management of this hospital, my experience tells me that it is likely that the safety culture of that unit and the hospital contributed to the error. Nurse staffing represents both a management and leadership responsibility, which encompasses the hiring of adequate numbers of nurses to provide high-quality care, sufficient preparation of nurses to work in specific patient care areas, and ongoing assurance of their continued competence. These responsibilities should be a priority for hospitals committed to patient safety, not a simple operational function. The increasing national attention to these aspects of leadership is a welcome development.(11,12) Although individual nurses are, and should be, held accountable for their actions leading to errors, health care organizations and leaders should use cases like this one to explore their possible contributions as well.

Take-Home Points

  • Due to their proximity at the bedside, nurses are frequently involved in medication errors, but they also serve important roles in error prevention.
  • Although research has focused on nurse staffing ratios as a mechanism to improve the quality and safety of care, practical aspects of nurse scheduling and competencies represent an equally important but underappreciated role in errors at the bedside.
  • The key to effective error reporting and the ability for it to motivate system changes depends on an institution's ability to promote a culture of safety.

Mary E. Foley, MS, RN
Associate Director, Center for Research & Innovation in Patient Care
Associate Clinical Professor, Department of Physiological Nursing
University of California, San Francisco School of Nursing
Past President, American Nurses Association

References

1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34. [ go to PubMed ]

2. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897-1903. [ go to PubMed ]

3. Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43. [ go to PubMed ]

4. Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2004. Available at: http://www.nap.edu/books/0309090679/html/

5. Aiken LH. The unfinished patient safety agenda [Perspective]. AHRQ WebM&M [serial online]. July/August 2005. Available at: /perspectives/perspective/7. Accessed October 18, 2005.

6. Wieland D, Cohen M, Wieman R. Medication errors—what happens afterward? Nurs Life. 1987;7:41-42. [ go to PubMed ]

7. VHA's Risk Management Policy and Performance: Hearings of the Subcommittee on Health of the House Committee on Veterans' Affairs, 105th Cong, 1st Sess. (October 8, 1997) (Statement of Lucian Leape, MD, Harvard School of Public Health). Available at: http://commdocs.house.gov/committees/vets/hvr100897.000/hvr100897_0f.htm

8. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Admin. 2002;32:509-523. [ go to PubMed ]

9. American Nurses Association. Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Publishing; 2001. Available at: http://www.nursingworld.org/ethics/chcode.htm

10. Marx D. Patient Safety and the ''Just Culture'': A Primer for Health Care Executives. New York, NY: Columbia University; 2001. Available at: http://www.mers-tm.net/support/marx_primer.pdf

11. Kohn LT, Corrigan JM, Donaldson MS, eds, Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. Available at: http://www.nap.edu/books/0309068371/html/

12. Creating and sustaining a culture of safety. In: Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press; 2004:286-311. Available at: http://www.nap.edu/books/0309090679/html/286.html

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