A reflection on personal reminiscence


Drug is prescribed by the physician and is dispensed by the pharmacist, but nurses do have the key job for administering medication. Medication errors do occur and are a persistent problem associated with nursing practice. The experience described here covers a wealth of challenging issues suggestive of those we as nurses meet in professional practice on a day-to-day basis. This reflection takes me 13 years back in my professional career when I joined Post Anesthesia Care unit (PACU) as a nursing intern. As we all know that the PACU is a high-acuity critical care environment where patients are kept to recover in the immediate postoperative period after receiving anesthesia. While commenting on PACU staffing Hicks, R.W., Becker, S.C, Krenzischeck, D, & Beyea, S.C, (2004) said: "PACUs are normally staffed by RNs with a wide range of backgrounds and expertise in areas such as critical care; plastic surgery; and emergency, orthopedic, cardiology, and gynecologic nursing." (p. 414). Internationally nurses are not placed in critical care units until they have at least two years of working experience in medical-surgical units; however, due to staffing crisis the nursing interns in our setting are placed directly into critical care setting. Hicks, R.W., Becker, S.C, Krenzischeck, D, & Beyea, S.C, (2004) said: "Unique situations exist in the PACU that create additional risk for patients. The complexity of care, the fast-paced nature of the PACU, and the needs of a surgical department to maintain the patient flow among the various pre- and postsurgical areas contribute to the risk for medication errors to occur." Although this incidence is rooted 13 years back it still knocks my heart and soul every day, every night. I still remember it was only a month of my professional career and I was going through "reality shocks" of my staff life. It was a lot busier and the patients were probably sicker than I expected. I didn't realise I'd be looking after sick patients every day, there wasn't actually any let up from it. I had started realizing the uniqueness of PACU world and I was witnessing that nurses working in the PACU were truly at the "sharp end" of care. I had started realizing that PACU nurses are highly vulnerable to error as these nurses were involved in performing various tasks hurriedly. These tasks included, but certainly not limited to ongoing assessment, critical evaluation of patients' responses, verbal and nonverbal communication with the patient and the health care team members, and administration of many medications. With the busy pace, the severity of several postoperative patients in the PACU at a time, and the need to move patients through the recovery phase, can potentiate the possibility of errors.


It was one of the busy evening shifts when around 1900 hours a patient Mr. G was received from operating room after going through ORIF Right femur. Nurse "A" received patient from anesthetist, attached oxygen and cardiac monitor to him and assessed his Post Anesthesia Recovery (PAR) Score which was 8/10 as the patient was in arousbale state. After few minutes nurse "A" received patient's file from primary surgeon and checked for post operative orders. Doctor had prescribed "injection Benzyl Penicillin 600,000 units intravenous stat". (During those days we did not have computerized physician order entry (POE) system). Hence, the nurse carried out the medication manual order on file and sent it to pharmacy. After 15 minutes pharmacist dispensed the drug. It was around 2000 hours when the drug was received in PACU and the dinner break had started. Nurse "A" was called by one of her friends to go for "break. I still remember the answer she gave, "just a minute, I need to administer medication to patient Mr. G". She administered the drug, handed over patient to another RN and left for dinner. During her break time an anesthetist Dr. M came to assess the patient as it was more than 1.5 hours since patient had arrived in PACU. To our surprise when Dr. M tried to arouse patient the patient was unresponsive. A code was called and the team started their resuscitative efforts. Call it luck that I had not witnessed any code situation during my student life and this was for the first time in professional life that when I was not only witnessing the code, but was part of actual code team. Luckily, patient's heart and respiratory functions were restored. By this time RN "A" had returned from her break. Although, patient's cardiac and respiratory functions were restored, patient was still unresponsive. The primary team and anesthesia were really surprised and so was the nursing team as what went wrong during the recovery period? While reviewing the course of actions from pre-operative stage till arrival in PACU there wasn't any untoward event. This forced all of us think "something" went wrong in PACU. By this time night shift had arrived and was ready for hands-off. The evening shift in charge nurse was asked to stay back till the investigations are carried out. Along with this particular patient we had 04 other patients in PACU waiting to be shifted to High dependency units and 02 operating rooms were running. This was an unusual situation during those days as routinely ORs were not functional during night shifts except for emergency cases; therefore, PACU routine staffing during night shifts was consist of 02 nursing staff in which one should be registered nurse. As the situation was unusual night shift in charge requested evening team leader if someone can work overtime for patient care coverage. As these were my earlier days I offered my help for doing extra shift which was granted. The wish for doing extra shift was also due to my impulsive nature as I wanted to know what went wrong. Luckily, as next day I had "day off" my supervisor allowed me to stay back as she said "being an intern this will be a learning experience for you." As the night shift staff got busy in taking care of other patients evening shift in charge along with the anesthetist and primary team carried out necessary investigations to rule out the cause of this incident. During a course of investigation, nursing documentation was reviewed and it was identified that besides routine immediate post operative care injection Benzyl Penicillin was administered as per physician's order. This "clicked" the physicians and nurse in charge to have a look at injection Benzyl Penicillin vial which was administered to the patient. All the danger boxes of PACU were emptied in search of a drug vial and when it was discovered it was like a "bomb shell" for all of us. Why? Because instead of Benzyl Penicillin pharmacy had dispensed injection Streptomycin and nurse "A" without reading the drug label had administered the drug. The recommended dose of injection Benzyl Penicillin is 3 million to 4 million units intravenous or intramuscular; whereas the maximum dose of injection streptomycin is 1 gm/day (I/M) and if given parentrally should be mixed with 100 ml of 0.9% normal saline and should be administered over 30-60 minutes. Nurse "A" actually had administered 6 million units of injection streptomycin intravenously and this had a fatal effect on patient and patient went into coma which afterwards confirmed as "brain death". The whole healthcare team presented there was under the state of shock and being a novice nurse I was so afraid that I actually started having palpitations. I could not believe that patient had died or to name it more correctly was "murdered" by a nurse. I had been doing medication administration under supervision first of my faculty at School of Nursing and then under clinical nurse instructor since I joined as an intern. I felt really de-skilled and really just felt like I'd lost my confidence when I witnessed this case there because this was all so new. I thought PACU was a whole different culture altogether, it was different as when you are working in the ward, you can easily swap from one ward to another ward without feeling de-skilled but here I felt all my skills were thrown out of the window, even the simplest tasks had become really difficult. The incident was alarming not only for PACU, but for the whole organization. Nurses across the board were questioned for their competency especially in terms of medication administration and many physicians accused us for compromising patients' safety. Being a PACU nurse I was also among the few frontline nurses from a particular unit which was highlighted and questioned across the hospital for safe nursing practices. I still remember the hardships we faced from anesthetist to surgeons to radiographers to hospital administrators. Everyone seemed to be suspicious about our practices and challenged our routine care as well. It was very different from what I had experienced in my student life; particularly in terms of competency. I had never realized I needed to know so much to work there. I also felt that post incidence we being novice nurses were really given "tough" orientation programme in order to ensure "safe practices". Although, I did not like that strictness during that time as my clinical instructor and Head Nurse used to keep an eye on every little action we took. I now can realize how beneficial it was as that attitude cultivated best practices among us. Going back to the incident described earlier I would like to reflect on the consequences of this incident. The "Root Cause Analysis (RCA)" revealed that pharmacist had dispensed injection streptomycin instead of benzyl penicillin as these were "look alike" drug. The pharmacist failed to double check the drug before dispensation and nurse also did not follow the rights of medication administration. As this had led to a sentinel event hospital administration after thorough investigations decided to terminate both the employees (pharmacist and nurse) as they both were found guilty. The license of nurse was also revoked. However, the suffering does not end here. The patient who suffered from a permanent loss was only 44 years old gentleman who had come from remote area of the country, was father of 04 young daughters and the only bread earner. Nothing could've substituted the loss which the poor family had gone through. However, as compensation hospital administration decided to provide conservative management till the patient is "clinically" alive without any cost. The patient was placed in a private room and unit nursing staff was responsible for providing basic nursing care. This has taught me a lesson in very early days of my career that no single provider alone can be accountable for a medication error. Rather, errors repeatedly start off with one provider and are continued through the medication use process by others. Patient safety literature consistently discusses the fact that medication errors result from system errors and are generally not the result of one health care practitioner's actions. This particular incident had series of mishaps which ultimately led to disaster. Foremost, the two potentially life threatening drugs did not have separate color codes for identification. Secondly, pharmacist failed to follow the correct dispensation protocol and the hospital also did not have any system which could alert the pharmacist to recheck look alike drug before dispensation. Finally, the nurse who actually administered the wrong drug due to non compliance with the standards of checking five rights of medication administration.


After several years of suffering in the same vegetative state the patient died last year, but this incident has proven to be a turning point in our organizational moves towards patient safety programme. This incident was notified to the respective pharmaceutical company in order to resolve the issue of "look alike" drug. After several meetings between hospital administration and pharmaceutical company executives the label of injection streptomycin was changed from green to blue; whereas benzyl penicillin remained green so the users can distinguish between 02 drugs. Hospital also decided to move from manual medication system to Computerized Physician Order Entry (CPOE) which is safer mode of medication management and usage. Stone, Smith , Shaft, Nelson & Money (2009) said, "The intended consequence of CPOE systems is to provide a safer environment for the ordering process, thereby decreasing medication errors." (p. 962). The concept of "Point of care pharmacist" has also been introduced. This positions the pharmacist as a regular resource member on the patient care team, working with medical staff to ensure rational prescribing of cost-effective medications, working with patients to improve their knowledge of the medications that they receive, and partnering with nursing to reduce unnecessary delays in the medication use system and improve overall patient safety. According to American Hospital Association in its December 7, 1999 advisory recommended that hospitals "ensure the availability of pharmacy expertise by having pharmacy personnel make daily rounds on units, or enter orders directly into computer terminals on patient care units." The pharmacists are used as a source of information, can resolve medication system problems, can participate in performance improvement activities, and provide education to nurses and patients at the bedside as indicated. I believe that the ability to learn from past experiences enables health care providers to make better choices in the future. Although this analysis illustrates a negative side of our care, the lessons learnt helped us in promoting patient safety practices across the institution. The insight generated through this reflection can provide an impetus that patient safety involves all health care providers who provide patient care.

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