Is the Nurse Incompetent?

This case is prompting a lot of comments, some of them taking issue with the concept of systemic failures and instead asserting that the young nurse was clearly incompetent, in that her error was inexplicable.  So, let’s turn from a clinic in Brazil to a recent case in a hospital in the US, cited in this article on AHRQ’s Web M&M.  A summary:

The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV. The drug-dispensing machines stocked phenytoin in 250 mg/1 mL vials. The correct dose therefore would require 4 vials and be equal to 3.2 mL to be added to a small IV bag. The nurse misread the order as 8000 mg (8 g) and proceeded to administer that dose to the patient, which was a 10-fold overdose and 2 to 3 times the lethal dose. The patient died several minutes after the infusion.

This nurse had to work hard to make the error:

An audit of the pharmacy system revealed that the nurse had taken 32 vials out of 3 different pharmacy dispensing machines to accumulate 8 g of IV phenytoin. Moreover, the nurse had to use two IV bags and a piggyback line to give that large a dose.

And all this had to go unnoticed by people nearby:

Within 100 feet of the ED nurses’ station were several ED doctors, a number of nurses, and a pharmacy with a PhD pharmacist on duty. The nurse did not ask anyone to check her calculations, nor did anyone notice or comment when she was moving around the unit amassing the vials needed for the dose.

What do we conclude? Elizabeth Manias writes:

In this case, the nurse made a series of cognitive errors that contributed to a 10-fold overdose of phenytoin. The nurse did not recognize that it was unusual to use 32 vials of phenytoin to obtain the required dose. She did not acknowledge that it was uncommon to need two intravenous (IV) fluid bags to administer the single dose of phenytoin. The nurse also did not double-check the IV medication with another clinician. Most important, she appeared not to know the toxic dose of the medication she was administering.

Incompetent?  Not necessarily:

Every day, well-intentioned clinicians carry out their medication activities in environments that are set up to fail them. Mistakes with medications occur not because a clinician has been incompetent by making an error, but rather because this single act is the final link in a chain of failures.

Indeed, some of the worse mistakes come from good intentions:

In this case, one can imagine a well-meaning nurse trying to do everything she could to collect the medication for her allocated patient. Although her persistence is laudable, it is probably also an example of anchoring bias. When the order is so difficult to complete and so unusual, it is far more likely to be in error than to reflect an idiosyncrasy of the prescribing physician or the patient. While the nurse was undoubtedly trying to be helpful, the instinct of all clinicians has to change from one of “this is unusual, but I’ll just get it done” to “this is unusual, I wonder whether it is correct.”

So back to the nurse in Brazil.   I don’t know if she was incompetent.  I do know that variations of the kind of error she made happen thousands of times, even by highly trained folks.  Manias concludes with these take-home points:

  • Good communication between clinicians is a key factor to minimizing the risk of producing a medication error.
  • Clinicians can train themselves to recognize warnings associated with medication errors.
  • Medication errors generally occur as a result of system failures rather than faults produced by particular people.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

22 replies »

  1. Just came across this – reminded me of a situation I had when working in palliative care. We were using paper records, handwritten prescriptions, faxed to the pharmacy but transcribed to the MAR by a unit clerk, until the new MAR was printed out at midnight. I came on the night shift and saw an order for “Dilaudid 300mg”. Of course this is a huge order, but in palliative care some patients do get huge amounts of narcotics. When I doublechecked with the original order, it was (in poor handwriting but barely recognizable) “Dilantin 300mg”.

    Problems? 1. hand writing prescriptions, 2. having a non-clinical person transcribe orders into the MAR, 3. this not passing the eye of a pharmacist until hours later after the medication may have already been administered from ward stock. Had I administered this dose my career would be over and I might still be in jail. The hospital administration that allowed this risky situation would have got off scot-free. Just something to think about.

  2. Carol W I agree with your post. This nurse neglected to double check the right dose of the medication at the patients bedside. As a nurse myself I understand that we are human and we do make errors but I feel like the nurse should have know when mixing the 32 vials of medication that something just doesn’t seem right. I can remember from nursing school the instructors preach to us the 5 rights of medication administration which was completed negated in this case. I also would like to know why other colleagues didn’t notice the nurse mixing a medication that took 32 vials?!? This is very concerning!

  3. Stacy, I am so sorry for your loss. As it happens, too late for your sister I know, I happen to be working on fixing this very problem at a large teaching hospital in Boston. Modern medication pumps can do exactly what you describe. They can be programmed to recognize when a given medication has been programmed by the nurse to be given at too high or too low a dose. The system is not perfect though, it’s still very new technology.

  4. Systems vs Humans. Thus was it ever so. Humans design systems – over time, with the input of a plethora of disciplines and expertise, tweaking as they go to re-mediate things not thought of and the inevitable unintended consequences.

    Systems – good systems require the relentless pursuit of perfection by their creators and guardians – all of whom are human.

    When actors who are supposed to be subject to the system step outside of it, the response should be to tweak the system again to ensure the scenario can not occur again. It’s imperfect . Patient’s die, fingers are pointed and clinicians are apportioned blame, the guilt of which follows them to their own grave. We are humans and we are flawed and we are imperfect. Thus was it ever so.

  5. It is amazing to me that in the technology industry we live in that mistakes like this could happen. I am not a nurse but two months ago I lost my sister she was in and out of the hospital for months. The machines that they use to administer the medications have to be programmed to give a a specific dosage. I would think now days if a dose is being administered that would be considered toxic of a certain medication that they machine could pass off an error and not let the medication be dispensed until the amount put in is corrected.

  6. Wait a minute. The order may have been entered correctly on the CPOE machine, but, how was the order transformed for the nurse’s screen, and what did it say, exactly? There is an evasiveness in the report, description, and commentary on this point.

    I have seen defective interfaces transforming orders into what was not ordered, truncated numbers, and vague concentrations. There are cases on the MAUDE FDA database on this.

    It is entirely possible that there was a defective transformation by the CPOE machine for the nurse’s order screen and it actually stated, 8,000 mg.

    Because the computer is always correct, the nurse followed the order on her/his screen.

    The systemic failure in infrastructure is that no one knows the reality because what the nurses see on their screens is different from what the doctor sees.

  7. One recommendation I would make to ALL supervisors — I do this myself when I do presentations that may be a bit intimidating — is I start off the Q&A by saying “Boy, that’s a really good question,” no matter what the first question is. And I’ll do that a few times and then people will get that they shouldn;t be embarrassed to ask.

    That helps to create a learning environment.

    But my earlier point was, part of training is to learn how to know when to ask, and then was missing from the training.

    People have gone back and forth on whether to blame to nurse, the supervisor, training etc., but this incident was a bit like the fire at The Station nightclub in 2003. At least 6 independent mistakes were made. if any one of the mistakes had been avoided, 0 rather than 100 people would have been burned to death in the 4th-worst nightclub fire in US history.

    By contrast, the 1944 Coconut Grove fire, the worst, was inevitable. Flammable faux palm trees in a smoking-intensive environment with only one egress, a revolving door that quickly jammed. (It turned out that there was another one, but there were no EXIT signs back then.) We’ve progressed a great deal since then by learning from these tragedies. Today’s fire codes (ever noticed that all doors open outward and that revolving doors are always flanked by regular ones?) are a direct result of that fire and subsequent ones.

    So we can never eliminate hospital mistakes or even come close, but it is reassuring in a perverse way that a mistake like the one in Dr Levy’s vignette required the confluence of many different errors of commisson and omission. If we investigate and learn, like the NTSB in airline crashes, we can reduce these tragedies faster than the increasing complexity of hospital regimens increases the potential for them to happen.

  8. Toni,

    Coach John Wooden used to say, “You haven’t taught them if they haven’t learned.” You assume a level of training that may not have occurred. Can we expect people to recognize their own incompetence? When those of you above blame the nurse, you do not recognize the systemic errors inherent in this environment. Do any of you honestly believe that this person was ill-intentioned? No. Yes, she made an egregious error, but what would keep someone else from doing likewise? I often hear people in medicine disdainfully talk of errors made by others while saying quietly to themselves, “There but for the grace of God go I.” Being hard on the problem but soft on the person is the best policy if you really care about introducing and maintaining a learning environment, one in which constant process improvement occurs.

  9. Wow, like letting politicians and bureaucrats set policy will not risk situations like this, and yes I note it happened in another country, but I sincerely see these kind of incidents happening with some frequency once the law, conveniently to set in on 2014, to harm people.

    Hey, if I am wrong, no harm, no foul. But what if I am right?

  10. Danielle, I’m glad to see your post. The questions you raise are significant for today. And her experience is significant here. Somehow people believe that a brief (likely less than 2 months of orientation) is enough to make her competent in her position. Or perhaps she wasn’t even out of orientation. Then where is her preceptor? And do we know whether she was encouraged or derided when asking for help? ER’s are rife with adrenaline junkies who are more concerned about one upping someone else rather than being receptive to helping them. And for the other nurses who have posted such critical appraisals of the situation, that attitude is what keeps new nurses from speaking up about what they need help with.

  11. Determined MD, really???? you are going to assign this incompetence to the Patient protection and affordable care act? How is this part of the equation? Most of the benefits of the PPACA have not even kicked in yet. I am curious to hear how you feel any part of this law translates into poor performance in patient care.

  12. I have to agree with Carol W. I likewise, have not worked in 4 years in nursing, but my husband was just discharged from the Veterans Hospital in PA. They like most other private and civilian hospitals, have the dispensing system, even in the ER, the nurse had to scan both my husbands hospital bracelet and the label on the medication before it could be used. Any errors evoke a audible beep indicating that something is not right. Even without this safeguard system, I honestly don’t understand how this nurse young or not could have gotten this so wrong. First of all, I never gave a drug that I was not familiar with, without first checking the PDR to know not only common dosages, but side effects too. Anyone who would not be alarmed by the amount of vials used and did not take the time to look up or call to verify, then they are INCOMPETENT.

  13. I haven’t worked as a Nurse in almost 10 years and therefore have not worked with dispensing machines. My recollection is that the Nurses ID, the Patients ID, and the order are inputted by the Pharmacy and the nurse draws the meds from the drawer. The stock is then reduced by the amount used. That should be recorded under the patient ID and Nurses ID. Somdwhere along the way, this did not happen. Truely the Nurse did not follow protocol if she.did not doublecheck the order, and that was her responsibility.

  14. I think no matter who or what is at fault for this error we need to learn from it. Yes the nurse had to go through a great deal of terrible in order to mix this medication. That raises my concern to why is this institution operating in this manner? It also raises my concern to ask what else was happening in the life of this nurse at work? It is very simple to place blame it is difficult to create change. Did this nurse have enough resources to care for this patient? My opinion obviously not seeing pharmacy was not involved. What is the experience level of this nurse? Why aren’t there systems in place,notifying a clinical resource nurse or supervisor that allows nurses to ask for help? I think before anyone can pass judgment we need to ask a lot more questions on how to improve system errors versus human error. I then think we need to take all aspects of this nurses assignment, experience level and resources available and lastly the organization and how they manage education, pharmacy, and EMR.

  15. I have seen nurses take the full blame as end users of systemic
    ineptitude, but this isnt one of those. Dilantin is a really common med that even a nursing student would be familiar with. That and the fact that it is very rare to give anything in thousands, (I actually can’t think of anything except IM penicillin). This nurse somehow got so locked into the task she forgot everything important about her training.

  16. Very sad vignette. But, there are always extremes to life, so is this an indictment of the field of medicine and nursing, or just a terrible moment in health care? Hey, if PPACA stays as is, you will see this rote behavior among more and more clinicians as the way politicians and bureaucrats think leads to this kind of mentality. Do as told, independent thought and actions truly be damned. I still hope the loudest proponents of PPACA end up in clinical care situations that do them damage. It is the only way extremist and narrow minded people learn from mistakes.

  17. I know we are in an era of “Safe Culture” and “No blame” and I am aware that most medical errors are “system” errors and we have to make doing the right thing easy. That said…nursing is a profession that demands focus and thought. What trained nurse would use 32 vials and 2 piggy back IV bags and not stop and think “This seems excessive”. Sorry, I blame the nurse.

  18. A lesson that woudl apply here — that is in my book Why Nobody Believes the Numbers — is that in many, many situations, such as the one Dr. Levy describes, you don’t need to know the right answer.

    You simply need to be able to recognize a wrong answer. In this information-intensive era, finding a right answer is easy…if you are trained to look!

    Two excellent examples. First, about 20 years ago a dairy spiked its milk with 1000x too much Vitamin D. (You read that right.) Quite literally, no one at the dairy or its supplier noticed that too many orders were being placed for several weeks. One wouldn’t expect the supplier or procurement officer to know how much Vitamin D is needed off the top of his/her head. But s/he should be able to say, “hey, this can’t be right.”

    And in period shows like Mad Men, they never make mistakes when it’s obvious that a mistake can be made, like checking the songs and styles and cars against the era. But when no one recognizes the potential for a mistake, that’s when they get made. So for instance, one character referred to another as “obese,” a word simply not in lay parlance in 1965. But that would not have occurred to young scriptwriters today.

  19. Nice. Go after the nurse again.

    The answer is clearly both.

    The hospital is at fault for not making sure a process is in to prevent mistakes like this from happening.

    On the other hand, It took a pretty single minded act of determination to make an error of this magnitude. So not sure our nurse is up for the nurse of the year award ..

    On the other hand – as the author states – if you’re doing something and something about what you’re doing strikes you as not quite right you should stop what you’re doing and ask the question …

  20. ICUs and ERs are set up differently for medication management compared to other inpatient units. Generally, they are set up to allow “emergency” medication administration in code situations that do NOT require verification by a pharmacist.

    You can imagine a scenario where a guy with no pulse comes wheeled in the door, it is a little impractical to wait 5 minutes to give a code dose of epi because the pharmacist has to “verify” it first.

    The problem here is that thusfar ERs and ICUs havent figured out a way to segregate the “emergent/code” situations from the less urgent interventions where meds SHOULD be proofread by pharmacists. Furthermore, it is very possible that the EMR order was in fact “verified” by a pharmacist, but the actual DISPENSATION of the medication from the cabinet was not.

  21. The Joint Commission recommends that all IV orders be prepared by the pharmacy. I would think this error would have been caught by a licensed pharmacist.
    Lastly the Joint Commission recommends that automated dispensing cabinets (ADC) be tied into the hospitals electronic medical reord (EMR) system or at least the pharmacy system. Even without pharmacy making this product, having the ADC linked with the EMR would have preevented the nurse to take out of the ADC only the correct amount of drug necessary for that one dose.
    I would put the blame on the hospital not the nurse for allowing these antiquated , error prone systems to be in operation.