The Market Place continued on page 2. Inside This Issue

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1 Quarterly circulation approximately 237,000 to all RNs, LPNs, and student nurses in Ohio. VOLUME 7 NUMBER 2 MARCH 2014 The Market Place Speaks: Education of the Nurse Workforce by Dr. Doris Edwards, ONA Advancing Nursing Education Task Force Chair and Dean of Nursing Emerita, Capital University and Dr. Susan Stocker, ONA Advancing Nursing Education Task Force Member and Dean and Chief Administrative Officer Kent State University at Ashtabula When the Institute of Medicine (IOM) released its 2010 report on The Future of Nursing that included a recommendation for 80% of the nurse workforce to be Bachelor of Science in Nursing (BSN) prepared by 2020, 1 much discussion took place in the nursing community about how to accomplish this goal. Earlier in 2008, the American Nurses Association (ANA) House of Delegates took the position that legislation requiring that new RNs complete the BSN within ten years of licensure, exempting currently licensed RNs and associate degree (AD) and diploma students, is necessary to improve the quality and safety of care. 2 The 2009 House of Delegates of the Ohio Nurses Association (ONA) also adopted this position and ONA has worked toward implementation of BSN-in-Ten legislation in Ohio and across the country. Others believe that voluntary BSN degree completion and marketplace factors will be sufficient to reach this widely agreed upon IOM goal. Marketplace variables change rapidly in healthcare delivery and are affected by economics as well as by labor force ebbs and flows. Fears of paralyzing nurse shortages emerge whenever standards for the educational preparation of the nurse workforce are considered. Such discussions have been divisive in the profession for nearly half a century. As a compromise approach, the BSN-in-Ten initiative builds on the strengths of the current education system while recognizing that the education of the nurse workforce affects the quality and safety of care. The American Organization of Nurse Executives (AONE) surveyed its membership in the fall of 2011 to determine the extent to which healthcare organizations are adopting policies and practices to incentivize and assist nurses to complete BSN degrees. Slightly over half of the 300 respondents listed their organizations as a hospital or medical center. Facilities reporting were urban (47%), suburban (32%) and rural (21%) and were evenly divided by bed size. Thirty-five percent of facilities were under 201 beds, 33% reported their bed size as beds while another 32% stated their bed size as over 500 beds. 3 Over half of the 300 AONE survey respondents stated that their institution had a policy for preferential hiring of BSN-prepared nurses. Some nurse executives reported that their organizations are planning to adopt such a policy and others noted that they hire preferentially without a stated policy. Other institutions without a policy on BSN hiring are requiring their current RN staff to complete the BSN within five or six years. 3 In those organizations with a preferential policy for BSN-educated nurses, about half of those responding reported that quality of care and safety were their chief reasons. One nurse executive indicated in the survey that We embrace the evidence that supports that patient outcomes are better in organizations with a high number of BSN nurses. We also rely on our nurses to lead improvement efforts and bedside care, which requires them to be qualified to do so. AONE President Linda Caramanica and AONE CEO Pamela Thompson stated in 2012 that a well-educated nurse is better prepared for changes in technology, advanced treatments and protocols and most important, can offer better and safer patient care. As we work through the challenges of health care reform and advancing technology, it s in everyone s best interest to support advanced nursing education. 3 The Veterans Administration (VA) Office of Nursing Services 2011 Annual Report Future of Nursing is devoted to a review of how VA Nursing is addressing the implementation of the IOM recommendations. The VA Office of Nursing Services sets policy and goals nationally that are implemented locally which reflect their longstanding commitment to a well-educated nurse workforce and evidence-based practice. Each facility has a timetable for increasing its proportion of BSN and higher degreed nurse staff. 4 The Trinity Health system, headquartered in Livonia Michigan, has recently expanded to serve people and communities in 21 states, including Ohio, from coast to coast with 82 hospitals, 89 continuing care facilities and home health and hospice programs in urban, suburban and rural areas. 5 Writing to the Ohio Board of Nursing in support of BSN-in-Ten legislation in a June 20, 2012 letter, Senior CNO Gay Landstrom stated Our health care system is committed to providing the highest level of nursing and health care possible and has adopted the IOM goal of 80% BSN by We value our nurses who have worked hard to complete a hospital diploma or an associate degree in nursing and we encourage them to continue their education in order to provide even better nursing care. Legislation that requires a BSN within 10 years of graduation from a diploma or associate degree nursing program will help create the kind of workforce that offers the best patient outcomes and an increased level of safety for the public. 6 The Market Place continued on page 2 CALL FOR PROPOSALS 9th Nursing Professional Development Educators Conference The Ohio Nurses Association is planning the 9th Nursing Professional Development Educators Conference to be held on April 11, 2014 at OCLC Conference Center in Columbus, Ohio. Nurses are invited to submit proposals for a poster session. The conference is designed for CE and Staff Development educators in any setting. Posters need to be developed to assist educators in making CE and/or staff development more effective, operational and easier. If you have a program or project that you would like to present in poster format, please complete the Request for Proposal forms and submit by April 1, Poster presenters must register and be available to present their poster during the poster session times. 2. ONA will supply one easel and one chair per person for each poster presentation. No tables are available. 3. Posters should not exceed 30 by 39 in order to fit on the easel. 4. No audio-visual equipment will be available. 5. The fee for poster presenters is $50.00 for each presenter. This includes the lunch, easel, chair and handouts. If you are attending the conference, you do not need to pay the $50.00 fee. 6. Please note that participants will be able to receive contact hours for participating in the review of the posters and discussions with the presenters. For questions or the Request for Proposal forms, please contact Sandy Swearingen, Continuing Education, Ohio Nurses Association, 4000 E. Main St., Columbus, Ohio (Phone: ; Fax: ; sswearingen@ohnurses.org) current resident or Non-Profit Org. U.S. Postage Paid Princeton, MN Permit No. 14 Inside This Issue The Retired Nurses Forum of the Ohio Nurses Association present: Future Directions of Nursing and Healthcare... 2 CE4Nurses.org... 2 Independent Study Registration and Instructions... 3 Nursing Law and Rules in Ohio: An Overview Ohio Nurses Association Continuing Education Activities Dates for Screening and Intervening with Suicidal Patients... 9 Are You Prepared to Prevent Medication Errors?

2 Page 2 Ohio Nurse March 2014 Published by: Arthur L. Davis Publishing Agency, Inc. The Market Place continued from page 1 At the Ohio State University Medical Center (OSUMC), Chief Nursing Officer (CNO) Dr. Mary Nash stated that We do prefer to hire BSNs and are willing to commit to having them complete the BSN in 5 years if they do not already have a BSN. All managers must obtain a masters degree by She noted that the OSUMC is developing a policy on education requirements for staff nurses and managers. The institution offers tuition remission, Graduate Record Exam (GRE) prep classes, an online BSN completion program with the OSU College of Nursing, and flexible scheduling to support its staff in advancing their educational preparation. Dr. Nash believes that the Magnet Designation and the compelling evidence on increases in quality of care given by BSN staff along with the IOM report are additional reasons to have a firm policy in place that is enforced. 7 CNO Catherine Koppelman at University Hospitals Cleveland and Associate CNO Joan Kavanagh at the Cleveland Clinic indicate that both institutions arrived at their current hiring and retention policies through broadly consultative processes. New hires have five years to complete the BSN. Koppelman also notes the influence of the Magnet recognition program. 8 At Metro Health Cleveland, also a Magnet facility, new associate degree (AD) graduates have three years to complete the BSN. CNO Mavis Bechtle and Director of Nursing Operations and Professional Development Melissa Kline say that they encourage staff to enroll in completion programs in cohorts so they can sustain one another. 8 All three Cleveland institutions offer tuition remission programs and other forms of support to staff in completion and graduate programs. 8,9 The Center to Champion Nursing in America (CCNA) with support from the Robert Wood Johnson Foundation A Compelling Memoir from TerryAnn Fisher, the battle of a mother losing her son to AIDS. Touching with hope and something to relate to for other parents of tragic children, Conversations with my Son is a moving read that other parents in grief shouldn t pass up. Midwest Book Review Search TerryAnn Fisher on FORTIS Nursing Programs RN to BSN Practical Nursing Associate Degree Nursing Programs Vary by Location Flexible Class Schedules Financial Aid Available for those who Qualify Career Placement Assistance for all Graduates (855) CENTERVILLE CINCINNATI COLUMBUS CUYAHOGA FALLS RAVENNA For consumer information visit Free Independent Studies All independent studies published in the Ohio Nurse are FREE to ONA members for three months and can also be completed online at Non-members can also complete the studies published in this issue online for $12 per study or by mailing in the tests provided for $15 per study. See page 3 for more details. Interested in joining ONA? See page 3 for membership information and five reasons for joining the only professional organization in Ohio for registered nurses. (RWJF) has organized state action coalitions toward achieving the wide ranging recommendations of the IOM Report. 10 The Ohio Action Coalition (OAC) is composed of diverse health related organizations from across Ohio committed to meeting all the IOM Report goals. The CCNA and OAC have stated their belief that a voluntary approach to reaching the targeted BSN prepared proportion of the nurse workforce will be adequate without legislation. There is merit to a voluntary approach in a national culture which increasingly finds mandates onerous. While one can debate the semantics between appropriate education standards set into statute and divisive mandates, members of the ONA Task Force on BSN Completion participate in the activities of the OAC through leadership and membership in the OAC working groups. In 2013 the marketplace is speaking: BSN and higher degree-prepared RNs are valued for the roles they play in a well-educated nurse workforce that leads the transformation of the healthcare delivery system. While marketplace influence is significant, the marketplace is also vulnerable to market forces yet unknown. Commitment to adopting sound and effective measures that increase the output of BSN completion and graduate programs is common ground all can support. References PolicyAdvocacy/State/IssuesResources/ NursingEducationAdvancement/Nursing-Education-Briefing- Paper-.pdf 3. Jan2012Voice.pdf 4. VA Office of Nursing Services 2011 Annual Report The Future of Nursing. Department of Veterans Affairs, Washington DC Letter to the Ohio Board of Nursing dated June 20, 2012 from Gay Landstrom with permission to quote 7. communication from Dr. Mary Nash on June 26, Interview with Catherine Koppelman on July 3, 3013 and communication from Joan Kavanagh on July 8, Phone interview with Mavis Bechtle and Melissa Kline on June 28, OHIO NURSE The official publication of the Ohio Nurses Foundation, 4000 East Main St., Columbus, OH , (614) Web site: Articles appearing in the Ohio Nurse are presented for informational purposes only and are not intended as legal or medical advice and should not be used in lieu of such advice. For specific legal advice, readers should contact their legal counsel. ONF Board of Directors Officers Shirley Fields McCoy, Shirley Hemminger, Chairperson Secretary Orient Cleveland Kathryn Peppe, Treasurer Columbus Davina Gosnell, Trustee Kent Daniel Kirkpatrick, Trustee Fairborn Gingy Harshey-Meade, President & CEO Reynoldsburg Linda Riazi-Kermani, Trustee Akron Diane Winfrey, Trustee Shaker Heights Johanna Edwards, Trustee Norton The Ohio Nurse is published quarterly in March, June, September and December. Address Changes: Send address changes to Lisa Walker, lwalker@ohnurses.org / For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) , sales@aldpub.com. ONF and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement. Acceptance of advertising does not imply endorsement or approval by the Ohio Nurses Foundation of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this Foundation disapproves of the product or its use. ONF and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ONF. The Retired Nurses Forum of the Ohio Nurses Association present: Future Directions of Nursing and Healthcare June 3-4, 2014 Ohio Nurses Association, Columbus Topics will include: Affordable Care Act Transplant Updates Parish Nursing Medical Nursing Missions Maintaining Skills Identify Theft Human Trafficking Emergency Preparedness Contact hours will be awarded. Criteria for successful completion include attendance at the entire event and submission of a completed evaluation form. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Please contact Sandy Swearingen for details and registration forms for this event at ; sswearingen@ohnurses.org The Ohio Nurses Association (OBN ) is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation.

3 March 2014 Ohio Nurse Page 3 Registration Form: Select the studies you are taking: Nursing Law and Rules in Ohio: An Overview Screening and Intervening with Suicidal Patients: Help for the Non-Psychiatric Nurse Are You Prepared to Prevent Medication Errors? Name: Address: Street City State Zip Day phone number: Address: RN or LPN? RN LPN ONA Member: YES NO ONA Member # (if applicable): ONA MEMBERS: Each study in this edition of the Ohio Nurse is free to members of ONA if postmarked by 5/31/14. Please send post-test and this completed form to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH Studies can also be completed for free by going to NON-ONA MEMBERS: Each study in this edition of the Ohio Nurse is $15.00 for non-ona Members. The studies can also be completed online at CE4Nurses.org for $12. Please send check payable to the Ohio Nurses Association along with post-test and this completed form to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH Credit cards will not be accepted. ADDITIONAL INDEPENDENT STUDIES Additional independent studies can be purchased for $15.00 plus shipping/handling for both ONA members and non-members. ($12.00 if taken online). A list is available online at ONA OFFICE USE ONLY Date received: Amount: Check No.: To help Ohio s nurses meet their obligation to stay current in their practice, three independent studies are published in this issue of the Ohio Nurse. Instructions to Complete Online 1. Go to 2. Click on each study you want to take and add it to your cart. (ONA members will see a price of $0.00 after they are logged in). 3. Complete the check-out process. You will receive a confirmation with instructions on how to take the test. 4. Go to the CE4Nurses Exam Manager ( org/survey) either from your confirmation or the CE4Nurses site. 5. Log in and click on View My New Studies. Click on the study you want to take, and follow the instructions provided in CE4Nurses Exam Manager to complete the study. 6. Please read the independent study carefully. 7. Complete the post-test and evaluation form for each study. Post-test The post-test will be scored immediately. If a score of 70 percent or better is achieved, you will be able to print a certificate. If a score of 70 percent is not achieved, you may take the test a second time. We recommend that the independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be made available immediately for printing. Independent Study Instructions Instructions to Complete By Mail 1. Please read the independent study carefully. 2. Complete the post-test and evaluation form for each study. 3. Fill out the registration form indicating which studies you have completed, and return originals or copies of the registration form, post test, evaluation and payment (if applicable) to: Ohio Nurses Association, 4000 East Main Street, Columbus, OH References References will be sent upon request. Questions Contact Sandy Swearingen ( , sswearingen@ ohnurses.org), or Zandra Ohri, MA, MS, RN, Director, Continuing Education ( , zohri@ohnurses.org). Disclaimer: The information in the studies published in this issue is intended for educational purposes only. It is not intended to provide legal and/or medical advice. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Join the Ohio Nurses Association The Ohio Nurses Association does a lot for the nursing profession as a whole, but what does ONA do for its members? FREE AND DISCOUNTED PRODUCTS AND SERVICES Members take advantage of a wide array of discounts on products and services, including professional liability insurance, continuing education, and special tuition rates to partner RN-to-BSN programs. WORKPLACE ADVOCACY ONA provides members access to a wide range of resources to help them make a real difference in the workplace, regardless of work setting. ONA provides members with resources to create healthy and safe work environments in all health care settings by providing tools to help nurses navigate workplace challenges, optimize patient outcomes and maximize career benefits. EDUCATION Whether you ve just begun your nursing career or are seeking to enhance or maintain your current practice, ONA offers numerous resources to guide you. For example, the Ohio Nurses Foundation awards several scholarships annually with preference to ONA members. Members also save up to $120 on certification through ANCC, and can earn contact hours for free through the independent studies in the Ohio Nurse or online at a discounted rate, among many other educational opportunities. NURSING PRACTICE ONA staff includes experts in nursing practice and policy that serve our members by interpreting the complexities of the Nurse Practice Act and addressing practice issues with a focus of ethical, legal and professional standards on a case-by-case basis. LEGISLATIVE ADVOCACY ONA gives members a direct link to the legislators that make decisions that affect nursing practice. Members can become Legislative Liaisons for their district, join the Health Policy Council and participate in the legislative process in many other ways through their ONA membership. These are just a few of the benefits nurses receive as ONA members. Dues range from $33 $50 a month and we offer reduced dues rates to new graduates, unemployed and retired nurses. Go to > Join/ Renew to start taking advantage of what ONA has to offer. Go to to join today!

4 Page 4 Ohio Nurse March 2014 Nursing Law and Rules in Ohio: An Overview Developed by: Carol Roe, JD, RN, Centers for Dialysis Care, Inc., Shaker Heights, Ohio. Revisions to this study were made by Jan Lanier, JD, RN, and Kathleen Morris, RN, Ohio Nurses Association. This independent study has been developed for nurses who wish to learn more about nursing law and rules in Ohio. The study was designed to be utilized with both Section 4723 of the Ohio Revised Code (ORC), (commonly known as the Nurse Practice Act) and Chapter 4723 of the Ohio Administrative Code (commonly known as Board rules). This independent study meets the Ohio Board of Nursing requirement for 1 contact hour of approved continuing education directly related to the law and rules governing nursing practice in Ohio. 1.0 contact hour of Category A (Law and Rules) will be awarded for successful completion of this independent study. The author and planning committee members have declared no conflict of interest. Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Expires 6/1/2015. Copyright 2002, 2004, 2006, 2008, 2010, 2013 by Ohio Nurses Association OBJECTIVES 1. Describe the difference in the role of the Ohio Board of Nursing and professional nursing associations in Ohio. 2. Describe the role of the Ohio General Assembly in establishing the Nurse Practice Act in Ohio. 3. Describe selected functions of the Ohio Board of Nursing. 4. Describe selected portions of the Nurse Practice Act and Board rules. STUDY The Role of the Ohio Board of Nursing The purpose of the Ohio Board of Nursing (OBN) is to protect the public. Nursing is regulated because it is one of the professions, if done by unqualified persons, that could pose a risk of harm to the public. The regulation of nurses, like that of physicians, pharmacists, and other health care professionals, is within the purview of the state government by virtue of the 10th amendment to the United States Constitution. Thus, the OBN is a structure of state government. The OBN is financially supported by the individual licensure fees which are paid by those who are regulated by the OBN. The payment of those fees is mandatory for those who wish to practice in Ohio. Because the OBN is a public body, its meetings are open to the public. The OBN s authority and decision making are defined by the law. The main purpose of the law is to protect the public from the unsafe practice of nursing and dialysis care. The nurse practice act in any state defines nursing practice and establishes standards for nurses in each state. It is the most definitive legal statute or legislative act regulating nursing practice (1). The nurse practice act in Ohio can be found in Title 47 of the Ohio Revised Code (ORC), specifically at Chapter ORC. The Nurse Practice Act is applicable to the practice of all licensed nurses, that is, registered nurses (RN), licensed practical nurses (LPN), certified nurse practitioners (CNP), certified nurse-midwives (CNM), certified registered nurse anesthetists (CRNA), and clinical nurse specialists (CNS). A change in the nurse practice act in 2000 led to the inclusion of dialysis technicians and in 2003, community health workers were added to the OBN s jurisdiction. In 2005, certified medication aides (MA- Cs) were recognized in Ohio law and became subject to Board of Nursing authority. The Nurse Practice Act grants the authority for enforcement of the law to the OBN. The law also gives the OBN the authority to adopt rules. The rules clarify or explain the law but cannot conflict with or expand the law. The rules can be found in the Ohio Administrative Code (OAC) and have the same force and effect as law. The OBN must enforce the law and rules regulating the practice of nursing as they are written even though individual nurses may not agree with the law. The OBN enforces the law and rules by taking disciplinary action against individuals who have been granted a license or certificate to practice from the OBN. The OBN has no authority over health care facilities or employers of nurses. It has no authority over individuals who are not licensed or certified by the OBN. The Role of Professional Nursing Organizations Professional nursing organizations are voluntary, private entities and the purposes, goals, and missions of the organization are determined by those who choose to be members of the organization. In general, purposes of professional nursing organizations include advocating for the advancement of the profession of nursing and protecting the public. These organizations bring the practitioners together and develop professional standards of practice, codes of ethics, and engage in peer review in a voluntary process. Professional nursing organizations provide services to members. In general, meetings in which decisions are made are open to only those who are members of the organization (2). There are a number of professional nursing organizations in Ohio. Additionally, dialysis technicians may belong to a voluntary organization comprised of dialysis technicians. The Ohio Board of Nursing works collaboratively with nursing organizations as well as other health care and consumer organizations. However, organizations do not dictate the actions of the OBN. In some instances, the OBN may make decisions that are not supported by an individual organization. One of the functions of some professional organizations is influencing the making of law through lobbying the state legislature. Indeed, one of the reasons for the establishment of the Ohio Nurses Association (ONA) in the early 20th century was to lobby the state legislature (Ohio General Assembly) to pass a Nurse Practice Act in Ohio. ONA is one of three state nursing organizations which employ lobbyists. The other two are the Ohio Association of Advanced Practice Nurses (OAAPN) and the Ohio State Association of Nurse Anesthetists (OSANA). The Role of the Ohio General Assembly in the Making of Nursing Law The Nurse Practice Act (NPA) is the law (also called statute) governing the practice of nursing in Ohio. Like any other state law, it comes into being through the legislative process. That means that a bill must be introduced, or another bill amended, in the Ohio General Assembly. The Ohio General Assembly is the legislative or law making body for the state of Ohio. Similar to the United States Congress, the Ohio General Assembly is made up of two houses, the Ohio Senate and the Ohio House of Representatives. The House of Representatives is comprised of 99 members and the Senate is comprised of 33 members. Any bill, which is being considered by the General Assembly, is public information and any citizen has an opportunity to provide input into the law making process. Thus, persons other than nurses make nursing law. Some nurses express disdain and frustration with the legislative process and vow never to be involved in politics. The reality is that the legislative process cannot be separated from politics in decisions about law. Changes in the nursing law can occur through one of two ways. A bill specific to the issue is introduced or another bill, which has been already introduced, is amended. After bills traverse the process of committee hearings and votes by both chambers, the legislation is sent to the governor for action. Legislation becomes effective, that is becomes law, normally 90 days after signature by the governor. The Role of Ohio Board of Nursing in Making Rules As previously stated, the Ohio Board of Nursing has been given statutory authority by the General Assembly to administer and enforce the Nurse Practice Act (Section (A), ORC). The OBN is authorized by law to issue all rules necessary to carry out the provisions of the law. As one example, the law states that continuing education is required in order to renew a nursing license or certificate (Section (C)(1), ORC). The specifics of meeting the CE requirement are spelled out in the rules (Chapter , OAC). All rules of the OBN are found in Chapters through of the Ohio Administrative Code (OAC). It is not enough to practice in accordance with the law; nurses must also practice in accordance with the rules. The rule making process for the OBN is set forth in another section of the Revised Code and is the same process for all state agencies which issue rules (Chapter 119, ORC). That process requires that the OBN review every one of its rules at least once every 5 years and determine whether the rule should be maintained as it is, revised or rescinded. In addition to the mandated five year review, the OBN may consider whether any other existent rule needs to be changed or if additional rules need to be proposed based upon new laws passed by the General Assembly. The OBN seeks public input into the rule making process in a variety of ways. A public hearing provides an opportunity for Board members to hear from those affected by the rule. The law requires the Board (like all other state agencies) to file its proposed rules with the Joint Committee on Agency Rule Review (JCARR), and other state entities. Ultimately, JCARR, which is comprised of members of the General Assembly, decides if the rules will be effective. Structure of the Ohio Board of Nursing The law dictates the composition of the Ohio Board of Nursing (Section , ORC). The OBN is made up of eight registered nurses (RN), four licensed practical nurses (LPN) and one consumer. Of the eight RNs, one must also be authorized to practice as an advanced practice nurse either a CNM, CNP, CRNA, or CNS. All of the nurse members must: reside in Ohio; be a graduate of an approved nursing education program; hold a current, valid Ohio license; and have engaged in the practice of nursing for the five years immediately preceding appointment to the OBN. The thirteenth member of the OBN represents the interests of consumers of nursing and dialysis care. The consumer member can have no association with or financial interest in the delivery or financing of health care. The term of office is four years with terms expiring at the end of the calendar year. Board members may be appointed to one additional four-year term. The expiration of terms is staggered so that all board members terms do not expire at the same time. The Governor appoints board members. Individuals who wish to be considered must contact the Governor s office to begin the appointment process. Nursing organizations as well as other organizations put forth suggestions to the Governor for appointment. Individuals who are seeking appointment need to take the necessary steps to lobby if they hope to be successful. The OBN as a whole meets every two months for two days to conduct the business of the OBN. Board members serve on Board Advisory Groups and Task Forces, which require additional meetings. Members are paid for a portion of their time spent in doing the work of the OBN. The OBN annually elects a President and Vice-President from its 12 nurse members. The law also requires that a registered nurse member be elected to serve as supervising member for disciplinary matters. The OBN appoints an Executive Director (ED) annually, who, according to law, must be a registered nurse (Section , ORC). The ED in turn hires staff to carry out the functions and directives of the board. The ED and various staff members may be present at board meetings and may be asked to speak to certain issues, but may not vote. The OBN, by law, may appoint Advisory Groups, which make recommendations to the OBN (Section , ORC). Currently, the Advisory Groups are: Advisory Group on Continuing Education Advisory Group on Dialysis. Qualifications for appointment to the Advisory Groups vary dependent upon the group. The requirements for the composition of the Dialysis Advisory Group as well as its functions are set forth in the law (Section , ORC) whereas the other Advisory Groups are created by the OBN. The law also mandates one other interdisciplinary committee, the Committee on Prescriptive Governance (CPG), (Section , ORC). This committee is comprised of a CNM, a CNP, a CNS, a registered nurse member of the OBN, four physicians, and two pharmacists. The CPG develops recommendations regarding the authority of all CNMs, CNPs, and CNSs to prescribe drugs. Recently, the Board began issuing so-called Interpretive Guidelines in response to questions raised regarding practice issues. Rather than maintaining an advisory group on practice and education, as had been the approach, the Board now convenes a Board Committee made up solely of Board members that then meets during the regular Board meetings. The committee obtains public input on the issue under discussion and gets feedback as to how proposed guideline language might affect practice. Scopes of Practice and Orders Registered nurse and licensed practical nurse Scopes of practice for those regulated by the OBN are found in varying places in the law. The scope of practice for the RN can be found in Section (B), ORC, which states: Practice of nursing as a registered nurse means providing to individuals and groups nursing care derived from the principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes: (1) Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen; (2) Executing a nursing regimen through the selection, performance, management and evaluation of nursing actions; (3) Assessing health status for the purpose of providing nursing care; (4) Providing health counseling and teaching; (5) Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s professional practice; (6) Teaching, administering, supervising, delegating, and evaluating nursing practice. Nursing Law and Rules continued on page 5

5 March 2014 Ohio Nurse Page 5 Nursing Law and Rules continued from page 4 In that same definition section of the law, Section (F), ORC, states: The practice of nursing as a licensed practical nurse means providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social and nursing sciences at the direction of a licensed physician, dentist, podiatrist, optometrist, chiropractor, or registered nurse. Such nursing care includes: (1) Observation, patient teaching, and care in a diversity of health care settings; (2) Contributions to the planning, implementation, and evaluation of nursing; (3) Administration of medications and treatments authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s practice, except that administration of intravenous therapy shall be performed only in accordance with section or of the Revised Code. Medications may be administered by a licensed practical nurse upon proof of completion of a course in medication administration approved by the Board of Nursing. (4) Administration to an adult of intravenous therapy authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s professional practice, on the condition that the licensed practical nurse is authorized under section or of the Revised Code to perform intravenous therapy and performs intravenous therapy only in accordance with those sections. (5) Delegation of nursing tasks as directed by a registered nurse. (6) Teaching nursing tasks to licensed practical nurses, individuals to whom the licensed practical nurse is authorized to delegate nursing tasks as directed by a registered nurse. A frequently asked question relates directly to the legal differences in the scope of practice of the RN and LPN. As can be seen by words of the law, the most fundamental difference defined is that of independent versus dependent functioning. The definition of the practice of nursing by the RN outlines six broad functions, five of which are independent functions meaning they can be initiated solely at the discretion of the RN after assessment of the situation and needs of the client. Conversely, all the functions set forth in the law for the LPN are defined as dependent functions, performed at the direction of the registered nurse, physician, dentist, optometrist, chiropractor, or podiatrist. This does not mean that the LPN can only practice in the presence of one of those individuals, but it does mean that the LPN cannot practice nursing independently. The entire scope of practice defined for the LPN must be done at the direction of one of the individuals listed in the law. Both the LPN and the healthcare professional directing the care must be aware of this fact. Additional legal differences between RNs and LPNs can be found in rules. The rules in Chapter ,OAC, which relate to pre-licensure nursing education programs, detail the differences in the curriculums of the RN and LPN programs as well as faculty preparation. Additionally, rules entitled, Standards of Safe Nursing Practice for Registered Nurses and Licensed Practical Nurses are found in Chapter , OAC. These rules outline the differences in the implementation of the nursing process by RNs and LPNs. Another frequently asked question relates to the issue of from whom can the RN or LPN take orders? The answer can be found in reviewing Section (B) (5) and (F)(3), ORC. Both the RN and LPN can administer medications and treatments which have been authorized by individuals licensed to practice in Ohio who are acting within their scope of practice. Thus, orders can be taken from a CNM, CNP, CRNA or CNS for ordering of diagnostic tests since that is within their scope of practice. Authority to prescribe medications may be granted by the OBN to qualified CNMs, CNP, and CNSs. RNs and LPNs working with those practitioners need to ascertain whether or not they have certificates to prescribe before they implement medication orders. Similarly, physician assistants may also prescribe medication under Ohio law and nurses may implement those orders in accordance with standards of safe practice set out in Chapter OAC. Advanced Practice Nurses Certified nurse-midwives (CNM); certified nurse practitioners (CNP); certified registered nurse anesthetists (CRNA) and clinical nurse specialists (CNS) The scopes of practice for these individuals can be found in Section , ORC, which states in part: A certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. Inherent in each of the four advanced scopes of practice is the concept that one cannot use any of the four titles without a certificate of authority (COA) from the OBN. This is known as Title Protection and applies also to the titles of registered nurse and licensed practical nurse. A commonality in the scopes of practice for the CNM, CNP, and CNS, is the requirement of a collaborative practice with a physician (or podiatrist) (Section (A), (C), and (D), ORC); the requirement of a standard care arrangement (Section , ORC); and the authority to prescribe medications under Section , ORC. This is in contrast to the CRNA scope that mandates supervision by a physician, podiatrist, or dentist (Section (B), ORC) and does not require a standard care arrangement. A CRNA is not required to obtain a certificate to prescribe in order to provide anesthesia care. The educational preparation and requirements of national certification for CNPs, CNMs, CRNAs and CNSs are set forth in Section , ORC. This is an important provision for registered nurses who may aspire to one of these four roles to keep in mind. In order to obtain a COA to practice as either a CNP, CNM, CRNA or CNS, an individual must have both graduate preparation with a major in a nursing specialty and certification from a national certifying organization which meets the criteria found in Section , ORC. Dialysis Technicians Dialysis technicians may do the following according to Section , ORC: Perform and monitor dialysis procedures, including initiating, monitoring, and discontinuing dialysis; Draw blood; Administer medications, which are limited to: - Intradermal lidocaine or therapeutically equivalent local anesthetic; - Intravenous heparin; - Intravenous normal saline; - Patient specific dialysate. - Oxygen, when it has been delegated by an RN. According to this same section of the law, dialysis technicians provide dialysis care only if the care has been delegated by a physician or registered nurse and the technician is under the supervision of the physician or registered nurse. Supervision is defined as in the immediate presence of that individual. Nursing Law and Rules continued on page 6 When you re ready to advance. You are ready for American Public University. Expand your opportunities with a CCNEaccredited RN to BSN program. APU can help you balance your personal and professional life while pursuing a respected degree online at the university that is the only 3-time Effective Practice Award winner from the Sloan Consortium. Visit: StudyatAPU.com/ALD We want you to make an informed decision about the university that s right for you. For more about our graduation rates, the median debt of students who completed each program, and other important information, visit

6 Page 6 Ohio Nurse March 2014 Nursing Law and Rules continued from page 5 Community Health Workers Section ORC Community health workers (CHW) are recognized by the OBN as community representatives who advocate for individuals and groups in the community by assisting them in accessing community health and supportive resources through the provision of such services as education, role modeling, outreach, home visits and referrals. The certification program under the auspices of the OBN recognizes these workers as members of the community in which they provide services with a unique perspective of community needs that enable them to develop culturally appropriate solutions to problems and translate the solutions into practice. When the services performed by CHWs involve nursing tasks, the tasks must be delegated and supervised by a registered nurse. Unlike the law applicable to nurses and dialysis technicians, certification by OBN is not mandatory for individuals acting in a community health worker capacity. That is, individuals who engage in the activities defined as the scope of practice for CHWs are not required to obtain certification from OBN. Doing so is voluntary. The law expressly prohibits CHWs from administering medications or performing any other activity that requires judgment based on nursing knowledge or expertise. Standards of Safe Nursing Practice The OBN has established minimal acceptable standards of safe and effective nursing practice for nurses (which includes advanced practice nurses) in any setting. Those standards can be found in Chapter , OAC. Among provisions in the chapter are: The duty to clarify orders (from any individual), about which the nurse may have concerns (Rules (E) and (F) and (E) and (F), OAC); The duty to maintain confidentiality (Rule (H), OAC and Rule (H), OAC); The duty to display the applicable title or initials when providing direct care to patients (Rule (A), OAC); The duty to promote a safe environment for each client (Rule (H), OAC); The duty to delineate, establish, and maintain professional boundaries with each client (Rule (I), OAC). Similar standards, which apply to dialysis technicians can be found in Rule , OAC. OBN rules also will set forth standards for community health workers in Rule OAC. Delegation Delegation rules can be found in Chapter , OAC. Delegation is the transfer of the responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who does not have the authority to perform the task. Nurses who delegate according to the rules minimize their risk of exposure to liability. Licensed nurses may not delegate medication administration to unlicensed individuals unless a specific law allows it. Examples of settings where a law allows delegation of the administration of some medications are: group homes under the auspices of the Ohio Department of Developmental Disability (OD/DD), county boards of intermediate care facilities for DD (Rule , OAC). Unlicensed individuals may assist patients with self-medication in any setting where self-administration is allowed. Basically, the delegation rules require a licensed nurse to assess the client, teach the task to an unlicensed assistive personnel (UAP), and supervise the performance of the task. The crucial factor in delegation is the exercise of nursing judgment by the nurse. Delegation is client or patient specific. It may be appropriate for a UAP to be taught a variety of nursing tasks. That does not mean the UAP should perform every task they are competent to perform on every patient. Tasks may be delegated to a UAP which: Require no judgment based upon nursing knowledge or expertise; Have reasonably predictable results; Can be performed safely according to exact, unchanging directions; The performance does not require complex observations or critical decisions; No repeated nursing assessments are required; There are no life threatening consequences. [See Rule (C)(3) OAC] Direct, on-site supervision is required for delegation if the substantial purpose of the setting is the provision of health care. The nurse is accountable for assessing the situation and is responsible for the decision to delegate. The nurses are accountable for the task which is delegated and UAPs are accountable for their own actions. Disciplinary Provisions One of the most misunderstood powers of the OBN is its role in disciplinary action. The grounds for disciplinary action and the process for that to occur are found in Section , ORC. These provisions apply to all nurses and dialysis technicians. Rules of the OBN establish standards-and procedures for imposing sanctions on community health workers [See Section (F) ORC] and medication aides [Rule OAC] and Rule OAC. The OBN does not take any disciplinary action without due process of law. In other words, there are no nursing board police who will take away your license immediately upon some error occurring. No action is taken by the OBN without an investigation of all the facts pertinent to the situation and an opportunity for the licensed nurse or dialysis technician, CHW or MA-C to explain. Any kind of action taken by the OBN, just like other regulating boards such as the medical and pharmacy boards, must be in accordance with Chapter 119 ORC, which sets forth strict rules for due process. The investigatory process by the OBN is initiated by the filing of a complaint. A complaint is evidence that demonstrates that a person has violated a provision (or provisions) of the law or the rules of the OBN. All complaints are evaluated to determine if the OBN has the authority to investigate. Complaints may be referred to another agency for investigation such as the Department of Health if the complaint falls within the authority of that agency. If the evidence gathered during the investigation warrants further action, formal charges will be made and the nurse or certificate holder will be sent a Notice of Opportunity for Hearing. The hearing is a formal process and both the OBN and the licensee or certificate holder presents his/her case before a hearing officer. Nurses or dialysis technicians, CHWs and MA-Cs who find themselves at this stage of disciplinary action should seek the advice of an attorney if they have not already done so. The hearing officer listens to both sides of the case, that is, the OBN s case setting forth the evidence of a violation and the licensee or certificate holder s explanation and/ or denial of wrongdoing. Both sides may present witnesses who may either have direct knowledge of the case or may be experts in the area in question. The hearing officer makes a determination based upon the evidence. If it is determined a violation or violations have occurred, the hearing officer recommends the level of disciplinary action. A range of options is available in terms of disciplinary action. The range includes: Permanent revocation prohibited from ever practicing nursing or dialysis care or as a CHW or MA-C. Indefinitely/automatically/immediately suspendedprohibited from practicing for specified time period after which the nurse, technician, CHW, or MA-C may request reinstatement. Indefinite suspension with stay on probation. May work as nurse or dialysis technician or CHW or MA-C but must be monitored and submit progress reports; may also have restrictions on practice. Restrictions have limits on such things as medication administration, shift work, or type of setting worked placed on their practice. Reprimand acknowledgement that something done was wrong. Does not prohibit practice, may include restrictions. Fines a fine of up to $ for each violation. Otherwise discipline examples include additional CE, take/retake certain education courses, write papers, public presentations, repeat nursing education dialysis technician, CHW or MA-C training program. The transcript of the hearing and the hearing officer s recommendations are reviewed by the members of the OBN with the exception of the supervising member who has been involved in the preparation of the case. The OBN members, having reviewed the materials prior to attending the board meeting, review the cases and hearing officer s recommendations during executive (that is, closed) session of a regular board meeting. They may accept or modify the recommendations of the hearing officer. The results of the OBN s deliberations are reported in open session. The OBN also has two programs which provide alternatives to disciplinary action: the Alternative Program and the Practice Intervention and Improvement Program. The goal of these non-disciplinary programs is to encourage early intervention and treatment or remediation to prevent harm to patients. The Alternative Program for Chemical Dependency (Section , ORC) is available to nurses, dialysis technicians and CHWs who have substance abuse problems. Individuals who enter this program must submit to the terms of the program, which include temporary voluntary surrender of the license or certificate issued by OBN and ongoing monitoring, for the duration of Nursing Law and Rules continued on page 7 There have been many twists and turns along your career path. But all along the way, you ve envisioned a better professional and personal destination. Now it s time to experience your dreams with a career at Yavapai Regional Medical Center in Prescott, Arizona. The acuity and advanced technology are just what you re used to. But living here is far beyond the expected. This is a place where you feel a strong sense of security and belonging. We are actively recruiting for a Nurse Practitioner to work as a Transitional Care Coordinator. We are also seeking a Director of our Care Management Department. Recruiting for current and future RNs in the following Departments: Cardiopulmonary Lab Care Management Critical Care Emergency Family Birthing L&D Imaging Services IV Therapy Med/Surg/Tele Pediatrics Surgical Services Take the first steps, visit us online at: call our recruiter at , or VIPCareerNetwork@yrmc.org. EOE Prescott, Arizona Two great hospitals. One caring spirit.

7 March 2014 Ohio Nurse Page 7 Nursing Law and Rules continued from page 6 participation in the program. Non-compliance with the terms and conditions will result in referral for disciplinary action by the OBN. The other alternative to discipline is the Practice Intervention and Improvement Program (PIIP) (Section , ORC). The OBN may refer individuals who have an identified practice deficiency that can be corrected through remediation to this program. Individuals who enter this program must complete the terms of remediation or be referred for disciplinary action. Please note, under current law, MA-Cs are not eligible to participate in either of the alternative programs. The OBN can only take disciplinary action in relationship to licensed nurses, dialysis technicians, and CHWs and MA-Cs. The OBN cannot discipline employers of nurses who may be coercing nurses to inappropriately delegate, nor can the OBN mandate staffing ratios. The OBN can, however, investigate complaints and, in some instances, the process of investigation provides an opportunity for education about nursing law. Check out the new CE4Nurses at Nursing Law and Rules in Ohio: An Overview Post-Test and Evaluation Form New & Improved No more confusing logins, cumbersome checkout and small text! Pick your course, read it at your convenience and pay when you re ready to submit it for grading. All courses are $12.00 it s that simple! DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question. The evaluation questions must be completed. Name: Date: Final Score: Please circle one answer. 1. The purpose of the Ohio Board of Nursing is to protect the jobs of nurses and dialysis technician. 2. The nurse practice act does not apply to advanced practice nurses. 3. Individual nurses and dialysis technicians voluntarily pay dues to belong to the Ohio Board of Nursing. 4. The Ohio General Assembly enacted the Nurse Practice Act. 5. The Governor appoints the members of the Ohio Board of Nursing. 6. The scope of practice for the RN and LPN is essentially the same. 7. Nurses may take orders for diagnostic tests from CNMs, CNPs, CNSs, and CRNAs. 8. Dialysis technicians provide care if it has been delegated by either a physician or registered nurse. 9. Both nurses and dialysis technicians have a duty to delineate, establish, and maintain professional boundaries with patients. 10. Nurses may delegate medication administration to unlicensed assistive personnel in hospitals. 11. Once a task is delegated by a nurse to an unlicensed assistive person, the nurse is no longer accountable. 12. The OBN can take away a license or certificate based upon a complaint being filed and a nurse might never have a chance to tell his/her side of the story. 13. The OBN can discipline an employer if the staffing is inadequate. 14. The OBN has a range of disciplinary actions available to utilize in the discipline of a nurse or dialysis technician. 15. The Board deliberates in executive session but actually makes disciplinary action decisions in public. 16. Individuals who have substance abuse problems can avoid discipline if they enter the Alternative Program for Chemical Dependency and abide by all the conditions of participation. 17. Unlicensed assistive personnel may assist patients with self-medication if the setting is one where the substantial purpose is NOT the provision of health care. 18. The OBN writes the laws for nurses and dialysis techs. 19. One of the reasons for the establishment of the Ohio Nurses Association was to lobby the state legislature to pass a Nurse Practice Act. 20. One of the 13 Board members is either a CNM, CNP, CRNA, or CNS. Evaluation 1. Were you able to achieve the YES NO following objectives? a. Describe the difference in the Yes No role of the Ohio Board of Nursing and professional nursing associations in Ohio. b. Describe the role of the Ohio Yes No General Assembly in establishing the Nurse Practice Act in Ohio. c. Describe selected functions of Yes No the Ohio Board of Nursing. d. Describe selected portions of Yes No the Nurse Practice Act and Board rules. 2. Was this independent study an Yes No effective method of learning? If no, please comment: 3. How long did it take you to complete the study, the post-test, and the evaluation form? 4. What other topics would you like to see addressed in an independent study? CE On the Go! Take your CE with you! Easily read courses and take post-tests on your laptop, tablet or smartphone! CE4Nurses is optimized for any browser and device. Certificates are ed to you so you can print them at your convenience. ONA Members Get 3 Free! ONA members still get 3 free courses per quarter. This quarter s coupon codes are below enter them at checkout instead of payment. Please don t share these codes with non-members it s a benefit exclusive to ONA members! KEEWAYDIN in Vermont summer camp positions: RN LPN If you are a qualified nurse who enjoys working with kids, consider a summer at Songadeewin of Keewaydin for girls or Keewaydin Dunmore for boys on beautiful Lake Dunmore in the heart of the Green Mountains of Vermont. Newly renovated Health Centers and private areas for Nurses. Keewaydin s website is Contact Ellen Flight at (802) or by at ellen@keewaydin.org MSN Add Mission YOUR ADVANCED NURSING PRACTICE Global Health track now offered online MSN Nursing Education APPLY TODAY! cedarville.edu/msn UTILIZE YOUR CLINICAL EXPERIENCE AND SHARE YOUR KNOWLEDGE Teach in the classroom Mentor and train in the hospital Educate in your community To learn more, visit or call

8 Page 8 Ohio Nurse March 2014 Ohio Nurses Association Continuing Education Activities Dates for 2014 Certified Registered Nurse Anesthetists in Ohio 9th Annual Nursing Professional Development Educators Conference (formerly called CE and Staff Development Educators Conference) 4/11/14 OCLC Conference Center, Dublin Topics will include: Leadership Aspirations of Registered Nurses: Who Wants to Follow Us? Planning Educational Activities From A to Z Creating an Interactive Nurse Residency Program: Redesigning Transition into Practice Teaching With a Story: Using Stories as an Effective Teaching Modality Contact hours will be awarded. Criteria for successful completion include attendance at the entire event and submission of a completed evaluation form. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Becoming An Approved Provider /12/2014 7/23/ /8/2014 Ohio Nurses Association, Columbus Objectives: 1. Identify the background for the continuing education process. 2. Discuss the rules and criteria to be used to develop an approved provider unit. 3. Describe the process in becoming approved as a provider contact hours will be awarded. Criteria for successful completion include attendance at the entire event and submission of a completed evaluation form. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Please contact Sandy Swearingen for details and registration forms for any of these events at ; sswearingen@ohnurses.org Join the Ohio Nurses Association Today! Visit for complete information 2014 DNP Poster Session 4/28/14 ONA, Columbus ~~~~~~~~~~~~~~~~~~~~~~~~~~ The Retired Nurses Forum of the Ohio Nurses Association present: Future Directions of Nursing and Healthcare June 3-4, 2014 Ohio Nurses Association, Columbus Topics will include: Affordable Care Act Transplant Updates Parish Nursing Medical Nursing Missions Maintaining Skills Identify Theft Human Trafficking Emergency Preparedness Contact hours will be awarded. Criteria for successful completion include attendance at the entire event and submission of a completed evaluation form. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. by Brian Kasson, CRNA, MSN Nurse anesthetists have a documented history of providing safe, high-quality anesthesia care. Today, nearly 150 years after the profession s humble yet heroic beginnings on the battlefields of the Civil War, Certified Registered Nurse Anesthetists (CRNAs) are the handson providers of more than 34 million anesthetics given to patients each year in the United States. There are over 1800 Ohio CRNAs who are the primary providers of anesthesia care in rural Ohio, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical, pain management and trauma stabilization services. There are currently 7 nurse anesthesia programs in Ohio that graduate over 150 CRNAs every year. CRNAs provide anesthesia services for surgeons, dentists, podiatrists, and other qualified healthcare professionals. When anesthesia is administered by a nurse anesthetist, it is recognized as the practice of nursing. As advanced practice registered nurses, CRNAs practice with a high degree of autonomy and professional respect. CRNAs practice in every setting in which anesthesia is delivered: traditional hospital surgical suites and obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities. In fact, nurse anesthetists have been the main providers of anesthesia care to U.S. military personnel on the front lines since WW I including the current conflicts in the Middle East. Managed care plans recognize CRNAs for providing high-quality anesthesia care with reduced expense to patients and insurance companies. This cost-efficiency of CRNAs helps control escalating healthcare costs. Nationally, the average 2012 malpractice premium for self-employed CRNAs was 33 percent lower than in 1988 (65 percent lower when adjusted for inflation) illustrating the everincreasing safety of nurse anesthesia. Legislation passed by Congress in 1986 made nurse anesthetists the first nursing specialty to be accorded direct reimbursement rights under the Medicare program. Demographically, more than 40 percent of nurse anesthetists are men, compared with less than 10 percent of nursing as a whole. Education and experience required to become a CRNA include: A Bachelor of Science in Nursing (BSN) or other appropriate baccalaureate degree. A current license as a registered nurse. At least one year of experience as a registered nurse in an acute care setting. Graduation with a minimum of a master s degree from an accredited nurse anesthesia educational program. As of Aug. 1, 2013 there were 113 accredited nurse anesthesia programs in the United States utilizing more than 2,200 active clinical sites; 16 of these programs award a doctoral degree for entry into practice. Nurse anesthesia programs range from months, depending upon university requirements. All programs include clinical training in university-based or large community hospitals. Pass the national certification examination following graduation. The future for nurse anesthesia in Ohio is particularly bright. As elements of the Affordable Care Act are implemented and Ohio works to expand health care coverage to more and more needy citizens there will be an increased demand for anesthesia services. It is the role of Ohio s CRNAs to meet that need with safe, high quality, cost-effective care that increases access for all those who require it. As the state association for Ohio s nurse anesthetists, the Ohio State Association of Nurse Anesthetists represents over 2,300 CRNAs and students. The mission of the OSANA is to promote and protect the scope of practice for nurse anesthetists through advocacy and education. As part of the association s public awareness campaign for 2013, OSANA produced an informational video to showcase CRNA practice. I encourage you to go to www. OSANA.org or use this QR code to view the OSANA promotional video.

9 March 2014 Ohio Nurse Page 9 Screening and Intervening with Suicidal Patients Help for the Non-Psychiatric Nurse Developed by: Angie Chesser, PhD, RN, CNS, BC This independent study has been developed for nurses to enhance understanding of how to screen and intervene with the suicidal patient. 1.6 contact hours will be awarded for successful completion of this independent study. The author and planning committee members have declared no conflict of interest. Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Expires 9/1/2015. Copyright 2010, 2013 Ohio Nurses Association OBJECTIVES 1. Describe personal issues that can impact nurses caring for suicidal patients. 2. Recognize risk factors for suicide. 3. Identify how non-psychiatric nurses can screen and respond to suicidal patients. STUDY Suicide impacts us all: Suicide leaves a lasting legacy of loss and pain in our society. Like a pebble thrown in a pond, its impact circles outward touching multiple lives in painfully indelible ways. Suicide is a major public health problem in America and worldwide. Each day in America a person dies by suicide every 16 minutes and more than 33,000 persons die by suicide each year. Of the persons who die by suicide each year, 90% had a diagnosable mental illness at the time of their death. Nurses, because of their contact with patients across multiple settings, have a crucial role to play in suicide prevention and intervention. Nurses interact daily with patients and their significant others experiencing health issues leading to loss and psychological pain. While suicidal thoughts and behaviors are often associated primarily with psychiatric patients and settings, in fact, many patients were found to have visited their primary care physician within three weeks prior to committing suicide. They expressed a variety of physical symptomatology often without definitive findings. Yet, they rarely directly shared suicidal thoughts or plans. While this finding can be anxiety provoking for caregivers, it also provides an enormous opportunity for intervening and preventing suicide. Nurses interacting with patients and significant others in multiple care settings across the entire life span from youth to old age can have a crucial role to play in reaching out to suicidal patients and saving many lives. Before nurses can reach out to potentially suicidal patients in a caring and effective way, it is important for them to do some self-reflection. This self-reflection can be protective to the nurse as working with suicidal patients can be a stressful personal challenge with potential physical and emotional impacts. Self-reflection also assists a nurse in examining beliefs and attitudes which can decrease their ability to reach out, assess and intervene with suicidal patients. Nurses can have personal beliefs, attitudes and emotional responses to suicidal patients which stem from many possible sources: upbringing, religious beliefs, social and/or cultural issues and the impact of suicide in their personal lives. It is crucial for nurses to identify and deal with their own issues regarding suicide because failure to do so can affect their ability to therapeutically assess and intervene with suicidal patients See Figure I for some self-reflection questions nurses can answer which may help identify potential personal issues that can hinder work with suicidal patients. Nurses can seek help with these issues through personal counseling and/or seeking clinical supervision when working with suicidal patients. FIGURE I Self Reflection about Suicidality Questions to ask yourself: 1) Do I believe suicidal patients are sinful, weak or shameful? 2) Do suicidal patients arouse high anxiety in me perhaps making me minimize warning signs or avoid caring for them? 3) Do suicidal patients elicit anger in me? 4) Do I feel the need to rescue suicidal patients? 5) Have I experienced intense guilt or rejection after a patient s suicide or attempt? 6) Do I have personal experience with a family member, friend or co-worker or patient committing suicide? Could my reactions to this event be impacting my care of suicidal patients now? 7) If I have a diagnosed mental illness, does working with suicidal patients worsen my symptoms? If you have concerns about working with suicidal patients, please: 1) Speak with your supervisor. 2) Seek personal counseling if needed. Next, nurses live in a society which stigmatizes suicide and mental illness. Stigma prejudice and bias against the mentally ill and those struggling with suicidal thoughts and behaviors make it more difficult for patients to share their pain and seek help. The media and the way it portrays suicide impacts the way we see suicide and persons who attempt or commit suicide. Research on media portrayals of suicide shows an increase in suicide when the number of stories increases, a suicide death is repeatedly reported, put on the front page or leads to evening news, and/or the reporting is very dramatic. Media portrayals of suicide may also reinforce misinformation or myths about suicide by suggesting that suicide often happens totally unexpectedly to otherwise healthy people or by romanticizing/idealizing suicide as a heroic choice. Suicide myths abound in our society. Nurses can play a key suicide prevention role by knowing about these myths and dispelling them through their work with patients, significant others, community educational opportunities and in their clinical practice. Here are some common suicide myths: 1) Myth: Asking a person about suicidal thoughts/behaviors may prompt them to commit suicide. Fact: Talking about suicide in an empathetic manner can decrease the likelihood of suicide. Directly asking about suicidal thoughts and behaviors can lower a person s sense of isolation and increase their sense that they are cared about and help is available. 2) Myth: Suicide happens without warning Fact: While some rare suicides occur without warning, most suicidal persons give verbal and non-verbal warnings of their distress and pain. Unfortunately, these communications may be missed or unheeded. 3) Myth: Suicide happens only to specific groups of people (certain gender, race, age, socioeconomic status, religion, cultural group, etc.) Fact: Suicidal thoughts and behaviors can affect anyone. 4) Myth: People who talk about suicide don t do it. Fact: Since many persons who have committed suicide are found to have tried verbally or non-verbally to signal their distress and it went unrecognized or unheeded, this is untrue. 5) Myth: People who talk about or make a suicide attempt are just seeking attention. Fact: Suicide talk and/or behaviors are a communication of pain and distress and always must be taken seriously. Persons seeking help by making a suicide attempt are at risk for dying by mistake. Whenever a person expresses suicidality, this must be assessed and appropriate clinical interventions applied. 6) Myth: A person who attempts suicide will not try it again. Fact: Since many persons who ultimately commit suicide have attempted suicide previously at least once, this is untrue. A history of prior suicide attempts increases a person s risk for suicide. 7) Myth: Persons who attempt suicide are intent on dying. Fact: This is untrue. Ambivalence about living or dying is common. The attempt may be a way to communicate feeling overwhelmed or hopeless. 8) Myth: When a depressed person s mood rises, the risk for suicide always lessens. Fact: This can be untrue. Through medication and/or counseling, a depressed person s energy level can rise yet feelings of hopelessness can still be present. The person may have been ruminating on how to commit suicide and now has energy to complete the act. Also when a depressed person decides on suicide as the best strategy to end their pain, their sense of relief can be seen as a lessening of their depression. For the remainder of this independent study, please refer to CE4Nurses.org and click on Ohio Nurse Independent Studies. Doctor of Nursing Practice (DNP) Post Masters (Online) Advanced Practice Nurse Nurse Executive The Graduate School GRADUATE NURSING Master of Science in Nursing (MSN) Choose from 3 majors: Clinical Nurse Leader Family Nurse Practitioner Nurse Anesthesia (7 semesters, full time) ADN to MSN Family Nurse Practitioner Clinical Nurse Leader QUESTIONS? CONTACT: Dorothy Crider, MS, RN (614) dcrider@otterbein.edu

10 Page 10 Ohio Nurse March 2014 Are You Prepared to Prevent Medication Errors? Developed by Barb Walton, MS, RN, NurseNotes INDEPENDENT STUDY This independent study has been developed for nurses who wish to learn more about how to prevent medication errors contact hours will be awarded for successful completion of this independent study. The author and planning committee members have declared no conflict of interest. Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy. The Ohio Nurses Association (OBN ) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Expires 1/2015. Copyright 2009, 2010, 2012 Ohio Nurses Association OBJECTIVES 1. Identify the Seven Rights of Medication Administration. 2. Identify types of problems and level of errors that can occur in medication administration. 3. List strategies nurses might use to assist in error proofing medication administration. 4. List strategies patients might use to assist in error proofing medication administration. STUDY A New Perspective for Medication Errors Changing the Culture from Blame to Safety. By now, everyone has probably heard of the landmark Institutes of Medicine Study (IOM), completed in 1999, bringing to light the number of deaths and complications caused by medication errors. As many of us nurses heard about the findings of this study, we thought back on medication errors we had witnessed or committed ourselves. Most nurses could tell you medication errors happen, sometimes with no untoward effect on the patient, while other errors we have witnessed have proven deadly. We all knew errors happen, but the importance of the IOM study was that it gave us the scope of the problem. It told us just how bad this problem is. Now that we are all aware of the scope of this problem, we need to focus on how to error proof our medication administration efforts. One key step toward error proofing is the recognition that errors will happen, even in the best of circumstances. Just think of the number of people involved in getting a medication into a patient. The physician or nurse practitioner prescribes; the manufacturer produces the medication, bottles and labels it; the pharmacist dispenses the medication; and the nurse, or patient or patient s caregiver then administers the medication. Now think about the possible errors that may occur with prescribing. Did the prescriber write a complete medication order? Is the dose missing? Is the route or frequency missing or unclear? To begin with, did the prescriber prescribe the correct medication for the patient s condition? What other problems or errors might the prescriber make? Think about manufacturer errors. Was the medication formulated correctly? Just recently it has been reported that Heparin solutions were incorrectly manufactured. Was the medication labeled correctly? Was it shipped to a pharmacy in correct conditions, i.e., it wasn t allowed to freeze or overheat? What errors might occur in the pharmacy? Did they dispense the correct medication? Correct dose? Did they make a substitute for a generic medication? Is it the correct substitution? Did they dispense the medication to the nursing unit in a timely fashion? Nurses make errors as well. They may give the medication to the wrong patient, the wrong dose to the correct patient, or give a medication at the incorrect time, just to name a few of the potential nursing errors. Now add patients and their home caregivers into the mix. As healthcare professionals, we understand medications, but do patients and their family members have the same understanding we do? How many times have you seen patients re-admitted to hospitals just because of medication mismanagement at home? Either they weren t taking the medications, or they were taking too much of a medication. There are a multitude of scenarios that can happen in the patient s home in taking medications-things we can t even imagine. For example, a patient I visited as a home care nurse was experiencing a variety of drug toxicities. When I visited her, I asked her to show me her medication vials. She brought out the pill containers for her digoxin, theophylline, furosemide and a few others; however, the containers were all empty. Upon asking her where were the pills, she produced a brown paper bag, and yes, all her medications had been poured into the paper bag! I next asked her how she took her medications. Her response was that she took two pills in the morning, two pills in the afternoon right after her favorite soap opera finished airing, and one pill at bedtime. She went on to say she couldn t read the labels on the pill containers due to her eyesight and poor printing on the label. She couldn t remember what pill to take when and often had difficulty opening the containers. To compensate for her deficits and the poor labeling, she would fill her prescriptions every month, come home, pry off the caps with a screwdriver and empty the pill containers into the sack. She then took two pills in the morning, two pills after her soap opera and one at bedtime using what I came to call the grab-bag method of medication administration. This is just one scenario. If you ask any nurse, she will have similar and many stories of mishaps with medications. With the historic IOM study came not only recognition of the magnitude of medication errors, but a recognition that competent individuals will make mistakes. In many instances, nurses have been punished for medication errors. With punishment comes a lack of reporting errors and the cycle swirls out of control. Now, in an effort to manage medication errors, we are in the midst of changing our culture from one of blame to one of safety. Competent health providers do not go to work thinking, What kind of medication error can I make today? We have recognized that it is the multitude of system problems that create medication errors. In other words, the system gets in the way of us doing our jobs correctly. Hence there is a shift from blaming and punishing individuals to one of safety, reporting errors, and fixing the system problems so as to prevent that particular error from re-occurring. Errors are now viewed as opportunities to fix our system or error proof our system as much as possible. How do we make this culture transition from blame to safety? The Women and Children s Hospital of Buffalo in Buffalo, New York undertook this shift successfully. They studied their medication error rates. They found many of the problems occurred when incomplete orders were written by prescribers. This often necessitated either phone calls to the prescriber, thus delaying dispensing and administration of the medication. Or simply, a pharmacist or nurse would complete the order themselves. It was decided the hospital would adopt a no incomplete medication order policy. One key step that was taken to make this transition was full administrative backing. In other words, the culture shift came from the top down. Administration further adopted a zero tolerance for incomplete prescriber orders. This represented quite a radical step and as one can imagine, quite a lot of initial resistance. But, if a faculty is truly committed to creating a culture of safety, tough decisions and tough actions to change our systems must be undertaken and fully supported by leadership. Culture change only occurs when leadership is willing to commit to it. Women and Children s Hospital of Buffalo did not have the funds to implement computer physician order entry or have computerized medication administration records. Hence, they used a low-tech approach to their problem. They simply changed the paper medication order sheet to a table format. (See sample below). Each column needed to be completed, or it was considered an incomplete order. Incomplete orders were returned to the prescriber for completion. Further, a committee tracked, for each prescriber, the number of incomplete orders written each month. This data was reported to the medical leadership and administration and each prescriber. The individual prescribers received their monthly incomplete order report confidentially, mailed to their home address. This created a sense of personal responsibility for each prescriber to make it their goal to have no incomplete orders. Over time, Women and Children s Hospital of Buffalo was able to accomplish the following remarkable results and successfully adopt a culture of safety: Reduced prescription rewrites by 58.5 percent Reduced incorrect dosing errors by 32.5 percent Reduced potential for adverse drug events by 36 percent Benefited from more than a $3 million combined cost savings Sample Medication Order Sheet Patient Identification Information Date/Time Medication Dose Frequency Route Indication Prescriber Signature 6/15/ Furosemide 40 mg Every day Orally Fluid retention, heart failure 6/15/08 Physical Therapy to see patient for gait training and strengthening please John Smith, MD Nate Allen, PAC Note when an order such as for Physical Therapy needed to be written, it is simply written across the columns, while medications were confined to each column. This simple, low-tech change in the medication order made significant improvements for Women and Children s Hospital of Buffalo and created a culture of safety. What might you and your leadership team be able to accomplish? What have you accomplished to date? The Five Rights Are Now the Seven Rights of Medication Administration. The gold standard we all learned in nursing school: The Five Rights of Medication Administration needs to be revised. The Five Rights, of course, include the right patient, drug, dose, route and time. The Five Rights have been taught as a procedure, when in fact, they are the goals or outcomes of correct medication administration. The goal is to get the right medication to the right patient at the right time via the right route. But what are your procedures for assuring you meet these goals? How do you assure you have the right patient? Do you always identify the patient via a wristband? Do you always ask the patient to state their name? Or do you ask the patient, Are you Mrs. Smith? Many of us have had experience of seeing a confused patient respond incorrectly to yes-no type questions. What is the best method for patient identification? Do you use a barcode reader to identify correct patient and medication? How do you know you have the correct medication in your hands? Do you use a unit dose system? Do you take the medication and the prescription or order to the bedside and identify the patient and correct medication, route and time before unwrapping the medication? How do you assure you are administering the medication via the correct route? How do you assure you are administering the medication at the correct time? Also importantly, do you do these things with each and every medication you administer to patients? How often do interruptions derail you from safe medication administration? If an order is incomplete or unclear, do you put timeliness in front of safety? Or do you stop and call for completeness and clarification before proceeding with medication administration? There is no single answer to any of these questions. However, what is important is that nurses establish procedures for themselves and within their work environments that assure The Five Rights, as goals, are met. We need to add two more rights, thus creating The Seven Rights of Medication Administration. Besides the right patient, drug, dose, route and time, we also need to identify the right indication or reason for the medication and the right documentation. Do you know why the patient is receiving that particular medication? A physician writes an order for aminophylline and indicates this is to treat an infection in a particular patient. Is this correct? Before administering the aminophylline, what actions would you take to assure you have the correct reason, patient or medication? Aminophylline is a bronchodilator, not an antibiotic. Did the physician mean the aminophylline for another patient? Or was the physician intending to prescribe ampicillin for this patient s infection, and simply confused the names of these medications? Certainly your actions would include clarifying the order with the prescriber before administering the medication. In regard to right documentation, we need to assure the medication order was written completely before administering the medication, and then after administering the medication, we need to document correctly that the medication was indeed given. How do you assure this occurs? How do you check medication orders before administering medications? How do you document medications you administered? Again, there is no single correct answer to these questions, but rather establishing habits or procedures to assure you meet the goals of The Seven Rights of Medication Administration. Is there an Eighth Right of Medication Administration? Besides the seven rights already discussed, we perhaps should consider an eighth right being the right outcome and recognition of side effects and complications for a particular medication. For example, if we are administering furosemide to a patient to ease fluid retention, do we see evidence of that? Does the patient have less pedal and/or sacral edema? Do they have clearer lung sounds? Are You Prepared continued on page 11

11 March 2014 Ohio Nurse Page 11 Are You Prepared continued from page 10 Have they experienced a weight reduction due to water loss or increased urine output since receiving furosemide? If their potassium level is now 2.5 meq/l, is that normal? Do we recognize hypokalemia as a side effect or complication of diuretic therapy and take appropriate action? Clearly, administering medications to patients is a very complex task. It isn t just as simple as taking the pill to the patient. Our brains are very complex and creative, and unfortunately, while we can create many great ideas, we can also create errors. But perhaps rethinking The Five Rights, thinking of them as The Seven (or even Eight) Rights will help us assure correct medication administration. Thinking of The Seven Rights as a goal or outcome and focusing on our procedures for meeting those goals, may help us greatly reduce medication errors. What are your procedures for assuring The Seven Rights of Medication Administration? How I assure the Right Patient; How I assure the Right Medication; How I assure the Right Dose; How I assure the Right Route; How I assure the Right Time; How I assure the Right Indication/Reason; How I assure the Right Documentation. The Need to Identify Errors: We see so many, we don t even recognize them! Have you ever thought about how much time you have spent correcting medication errors through the course of one shift or workday? How many times have you phoned pharmacy for missing doses of medications? How many times have you phoned a prescriber because they omitted a portion of a prescription such as frequency or route or other information? How many times have you phoned a prescriber because they prescribed a medication to which the patient is allergic? Have you ever questioned the generic substitute that was sent to you instead of what the physician ordered? Have you ever questioned an order when a patient states they can t take a certain medication or have hesitations about a certain medication? How many times have you questioned a dose written as 5.0 mg, when you thought it read 50 mg? We would probably be amazed at the number of times we do make additional phone calls regarding medications. In some settings, nurses have become so accustomed to catching and correcting errors, we don t even recognize them ourselves. It has been reported that nurses intercept 48% of the ordering errors made! We also catch 11% of the transcription errors made. In other words, we spend a lot of our time catching and correcting errors; thus, preventing near misses and worse, and we don t even know it! This creates another problem with preventing medication errors. Do you and your leadership truly know just how many and what type of errors are occurring in your workplace? In order to know how to proceed to correct errors, we have to know the magnitude of the errors being made. How many errors do you recognize in the following scenario? Ms. Weaver is an 84-year-old resident of an assisted living facility, with a past history of pulmonary embolism. She has been on warfarin for the past few years for anticoagulation therapy. She is admitted to the hospital for increased confusion and abdominal pain. A urinary tract infection is suspected. Due to the abdominal pain, her warfarin is discontinued in case she may require surgery for a suspected bowel obstruction. CT scan of her lungs, abdomen and heat all reveal no changes compared to previous studies and no acute problems. The urine culture returns as negative, thus ruling out a urinary tract infection. During the hospital stay, Ms. Weaver experiences some shortness of breath. It is thought she may have experienced another pulmonary embolism. Anticoagulant therapy is to be started. The hospital has a protocol for re-initiating anticoagulant therapy which requires a bolus of heparin followed by continuous intravenous infusion. Single dose vials of 5000 U/mL arrive from the pharmacy in a plastic bag. There are ten identical vials in the bag; nine of the vials contain heparin, the tenth vial contains a multivitamin solution. The physician caring for Ms. Weaver entered the orders for the heparin bolus and laboratory orders for partial thromboplastin times every six hours. There was no order for the continuous infusion of heparin following the bolus. The nurse pages the physician regarding this omission. When the physician arrives on the nursing unit, the nurse, again, informs him of the omission. The physician states he was not planning to order a continuous infusion of heparin. When the nurse questions this, the physician states he did not want to use an infusion, only boluses. The nurse asks the physician if he had intended to use the heparin protocol and he says yes. The nurse reminds the physician the protocol required a heparin bolus followed by continuous infusion, with the partial thromboplastin time being checked every six hours and heparin infusion then being adjusted accordingly. The physician reiterates he was only going to use boluses. The nurse reminds the physician the half-life of heparin was only fifty minutes, but still the physician insisted on boluses only. The nurse then suggests they contact the attending physician covering Ms. Weaver. Upon consulting the attending physician, the first physician writes the order for continuous heparin infusion. What errors do you identify in this case study? The errors in the above scenario include: An incorrect medication arrived from the pharmacy. A dose of multivitamin solution, which was not ordered and appeared identical to the heparin vials appeared in the same plastic bag as the heparin vials. Even if the multivitamin solution had been ordered for Ms. Weaver (which it wasn t in this case), it should be in its own plastic bag with its own label. Individual medications, especially medications that appear identical, should be separated and clearly labeled. The continuous infusion of heparin was not ordered. There was a lack of knowledge on the part of the physician as to the heparin protocol and the characteristics of heparin. Without the continuous infusion heparin, the boluses would not have been effective in achieving therapeutic anticoagulation. Without the continuous heparin infusion, the physician was not following the protocol. There is a failure of the physician to attend to the concerns voiced by the nurse regarding the continuous infusion of heparin. The nurse had to reiterate the heparin protocol a number of times, and still the physician would not order the continuous infusion. It was not until consulting the attending physician, at the request of the nurse, that the physician finally ordered the continuous infusion heparin. Types of errors: Coding and Tracking. There are a number of methodologies to track and code errors being used. Become familiar with your employer s methods so that you may be better prepared to recognize and report errors. There may be a separate committee that tracks medication errors, or it may be part of a safety committee or risk management committee to undertake such tasks. Ask for in-service education if you have not already become acquainted with your facility s system for tracking and coding errors. By classifying errors, it gives us more and better opportunities to manage the errors and work towards error proofing our systems. A first step is to identify the error as an active or latent error. Active errors are defined as the type of incident that is the result of non-compliance with a procedure. For example, not identifying the patient correctly before administering medication would be an active error. The healthcare professional was not compliant with the procedure of checking the patient s wrist I.D. bracelet and asking the patient to state their name. Thus, the wrong medication was administered to the patient. Active errors are usually made by those on the front lines of healthcare to include nurses, physicians, pharmacists, patients, and/or family members. Active errors are sometimes labeled as unsafe acts. Latent errors involve problems within the system. Often latent errors are longstanding problems, hidden in the system. Often it is not until an active error occurs, that the latent error gets recognized. Latent errors often involve policies, communication errors, and managerial decisions. An example of a latent error would be when a pharmacy stores the boxes of 1:1000 U concentration of heparin vials right next to the box of 1:10,000 U concentration of heparin vials. The vials are the same 10-mL size with similar labeling. The Agency for Healthcare Research and Quality (AHRQ) has identified several categories for classifying errors. Many facilities have adopted these categories to identify and code their errors. By using a standard method, facilities can compare their errors with other facilities using the same classification system. This can also lead to sharing of ideas and suggestions to solve problems amongst healthcare providers. The categories from AHRQ are as follows: Communication problems, both verbal and/or written communication along all levels of healthcare providers in various settings. Inadequate flow of information, the need for information to appropriately care for and manage the patient through the continuum of care. Human problems that include the lack of appropriate clinical knowledge, failure to follow policy and procedures. Patient related issues such as lack of appropriate patient education or lack of access to medications and treatments. Organizational knowledge transfer that includes lack of appropriate orientation, staff development, education and training. Staffing patterns such as inadequate staff and supervision can contribute to situations that are at high risk for medical errors. Technical failures such as medical equipment failure or occurrence of errors related to poor design or medical equipment. Inadequate policies and procedures or lack of procedures to guide the delivery of care. Remember the previous case study with the physician who did not write the order for the continuous heparin infusion? What categories of errors occurred in that scenario? There was a communication error in that he did not write the order. There was a human problem in that he did not follow the heparin protocol and it was certainly questionable as to his level of clinical knowledge regarding heparin when he wanted to pursue the anticoagulant therapy with only heparin boluses. There were further human problems on the part of the pharmacy when they dispensed the wrong medication (the multivitamin solution). While we don t know for sure, there may have been a problem with inadequate policies and procedures in dispensing medications. All the vials were sent from the pharmacy in one plastic bag. Shouldn t there be a policy that separate medications should be in their own separate bags? Besides categorizing the errors using the AHRQ classifications, it is also important to identify and classify the level or type of error. The level of error described the outcome for the patient. Levels of errors defined by the American Society of Hospital Pharmacists (ASHP) are as follows: Level 0 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 A potential for error occurred, but was caught and corrected before it got to the patient. Some facilities call these near misses. An error has occurred, but did not harm the patient. No further patient monitoring was required at the time. An error occurred and resulted in the need for increased patient monitoring, but there was no harm to the patient or changes in his or her vital signs. An error occurred that resulted in the need for increased patient monitoring with changes in his or her vital signs, but there was no ultimate harm to the patient, or any error that resulted in the need for increased laboratory monitoring, but no ultimate harm to the patient. An error occurred that resulted in the need for treatment with another medication or an increased length of stay, or that affected patient participation in an investigational drug study. An error occurred that resulted in permanent patient harm. An error occurred that resulted in patient death. Are You Prepared continued on page 12 I m inventing a new model of health care. Apply Today: VAcareers.va.gov/ALD Follow VA Careers

12 Page 12 Ohio Nurse March 2014 Are You Prepared continued from page 11 Thinking back to our heparin case study, what level(s) of error occurred in that scenario? The level of error that occurred is Level 0. All the errors were caught and corrected by the nurse. Ultimately, no harm was done to the patient. In our next section, we will be further investigating and analyzing medication error case studies. It is hoped that by examining these case studies it will create an awareness of potential errors we might make and how we can prevent them. We will be putting into use information we have discussed in the first half of this educational activity. The case studies actually occurred. These are real patients and real nurses. Names and identifying information have been masked to preserve confidentiality. Investigating Medication Errors The Case of the Blue Hand A twenty-six year old woman was admitted to the hospital to treat an abscess on the right side of her neck. She will be receiving IV antibiotics. She has a past history of systemic lupus erythmatosis, a suspected bleeding disorder that was not named, and Raynaud s syndrome. She was prescribed Konyne (clotting factors 5, 7 and 9) via IV to treat the suspected bleeding disorder. To treat the pain associated with the right neck abscess, the following pain medications were ordered: * Tylenol (acetaminophen), 650 mg orally every 4 to 6 hours as needed for mild pain. * Percocet 5 (5 mg oxycodone and 325 mg acetaminophen), one to two tablets orally every 4 to 6 hours as need for moderate pain. * Demerol (meperidine) 50 mg and Vistaril (hydroxyzine) 25 mg Intramuscularly, every 4 to 6 hours as needed for severe pain. The following is the sequence of events, as they appeared in the nurses notes, which occurred on her second day of admission. 3 PM Patient complained of pain in her left arm, Tylenol 650 mg was administered. 4 PM An IV was restarted in the left thumb. 8 PM Patient complaining of tingling of the left arm and fingers, IV is patent, no swelling noted. 10 PM Patient complaining of pain in the left hand and arm, IV patent. Slight swelling of the entire arm is noted. Cool to the touch and firm, slightly discolored. Radial pulse is present. 10:30 PM Dr. Blue is called. She prescribes Nitropaste, 3 inches to be rubbed on the left arm. Percocet 5, two tablets given for complaints of pain. IV removed from left arm. B. Smith RN 12:45 AM Patient continues to complain of arm pain. Arm continues to be dusky colored. Lower arm and hand are swollen. IV is restarted in the right hand. 3 AM Percocet 5, two tablets given for left arm pain. 4 AM Left arm and hand continue to be swollen, elevated on a pillow. J. Brown, RN 8 AM Left arm is edematous, hand is highly swollen. Finger joints are highly swollen and spongy like, Skin is cool with a dusky color. Unable to palpate a radial pulse due to edema. 10 AM Crying, complaint of much pain in left arm. Demerol 50 mg and Vistaril 25 mg given IM for complaints of severe pain. 11:30 AM Some relief noted, but pain is not completely gone. 12 PM Dr. Blue is in to see the patient. A venous Doppler study is ordered. Morphine Sulfate 5 mg IV every 4 to 6 hours as needed for severe pain is prescribed. 2 PM Morphine Sulfate 5 mg IV is administered for complaint of severe pain. Arm remains the same. Patient is transported to the vascular laboratory for the ordered venous Doppler study. 4 PM Returned from vascular laboratory. Left arm from shoulder to hand has major edema, is firm and two times the size of the right arm. From the elbow to the fingers the arm is pale purple/blue in color and is cool to the touch. A. Grey, RN. 6:45 PM Morphine Sulfate 5 mg IV is administered for complaints of severe left arm pain. 8:20 PM Dr. Green, vascular consult, is in talking with patient regarding the results of the venous Doppler study which revealed a thrombus of her left subclavian vein. 9:45 PM Patient was transferred to another hospital for subsequent thrombectomy followed by a left arm amputation at the shoulder. At the second hospital, it was determined the patient did not have any type of bleeding disorder. Let s analyze this case study. First of all, while we don t know all of this hospital s policies and procedures, we can identify some of the active and latent problems that exist in this case study. Take a moment to answer these questions What active and latent errors can be identified? In which categories do these problems fit? (AHRQ Categories) What level of error occurred here? (ASHP Levels of Errors) Active errors: Konyne (clotting factors 5, 7 and 9) was prescribed, but there were no orders for any coagulation times to follow the administration of this medication. Furthermore, the bleeding disorder was only suspected, should any medication have been ordered to treat this suspected problem? This may indicate a human problem (lack of clinical knowledge, and failure to follow protocols), on the part of the physician. An organizational knowledge problem (Lack of education and training regarding policies and procedures) and an inadequate policies and procedures problem may exist if there is no policy or protocol giving guidelines for ordering coagulation studies when one is administering either coagulants or anticoagulants. This would affect both the physician and nurses. There may also be a human problem (lack of clinical knowledge) on the part of the nurses regarding their knowledge of Konyne and the need to follow coagulation studies when administering this medication. If the nurses had a knowledge deficiency regarding the Konyne, they could have asked the physician and/or a pharmacist for information. In the absence of asking for information, this indicates a communication problem as well as a human problem on the part of the nurses. The pain medications (Tylenol, Percocet 5 and the Demerol and Vistaril) were ordered for the right neck pain. The nurses were administering these medications for left arm pain. The nurses were not using the pain medications for the indicated reason on the orders. This constitutes a medication error. Furthermore, we are not sure if the nurses communicated to the physician the fact they were using the pain medications for the left arm pain. This would indicate a communication problem and possibly an organizational knowledge problem (lack of education and training) as well as human problems (failure to follow policies and procedures) on the part of the nurse. If they had communicated to the physician they were administering the pain medication orders to include the left arm pain, the physician then needed to change the pain medication orders to include the left arm pain as an indication for medication use. Nitropaste was ordered at 10:30 PM; however, there is no indication or reason identified for this medication. This also constitutes a medication error in that the order is incomplete (lacking an indication). Why did the physician prescribe this medication? At a later time, the physician stated she prescribed the Nitropaste, thinking the patient was experiencing a Raynaud s syndrome problem. The indication for the Nitropaste is that it is a vasodilator and would improve circulation to the left arm. The physician stated she did not communicate this to the nurses and the nurses stated that they did not inquire as to the indication for the Nitropaste. Furthermore, the nurses stated they had no idea why the Nitropaste was being prescribed for this patient. The nurses stated they knew it was a cardiac medication, but that was all they knew about this medication. This creates not only a communication problem between the physicians and the nurses, it also points to a human problem (lack of clinical knowledge regarding the use of the Nitropaste) on the part of the nurses. Because of this lack of communication and lack of clinical knowledge, the nurses also failed to communicate with the physician when after applying the Nitropaste and the condition of the arm does not improve. One would expect that after applying the Nitropaste, the arm would pink up, but instead, it remained dusky and the patient continued to complain of pain. All of this should have been reported to the physician, but was not. This, perhaps, could be identified as a human problem (again, lack of clinical knowledge), and an inadequate flow of information problem (information was not relayed to the physician to appropriately care and manage the patient). Look back at the case study and review the pain this patient is experiencing. The pain is escalating, the nurses are using more and more potent analgesics and the patient is still not receiving adequate pain relief. We have already addressed the issues of the nurses administering the pain medications for left arm pain when they were indicated for right neck pain. But, wouldn t one expect to see the patient obtain pain relief with these medications? Thus, when the outcome was not obtained, it should have been communicated to the physician? Here is another communication problem and inadequate flow of information problem. The condition of the left arm is deteriorating in spite of the Nitropaste, pain medications, elevating it on a pillow and discontinuing the left thumb IV. Shouldn t have all this information have been communicated to the physician? Here again is a communication problem and inadequate flow of information problem. Had the nurses communicated the condition of the left arm to the physician after the patient received the Nitropaste, perhaps there would have been a happier outcome for this patient. When asked about why there was no follow up with the physician after applying the Nitropaste, the nurses stated the physician already knew the condition of the arm. They had followed her order for the Nitropaste and felt they did not need to communicate further with this physician. What other active problems can you identify? Latent Problems. Again, we don t know all the policies and procedures for this facility, but here may be some of the possible latent problems in this case. When questioned about why the nurses did not inquire about the indication for the Nitropaste, the nurses stated they didn t communicate much with this particular physician because she didn t communicate much with us. Furthermore, the nurses stated they might get into trouble if they questioned a physician too much or if they called physicians late at night too often. Perhaps there are institutional cultural issues here. If nurses are, indeed, punished for questioning orders or bothering a physician in the middle of the night, what kind of safety culture exists in this hospital? Are nurses being punished here for trying to maintain an adequate flow of information and communication? Are they being punished for trying to improve their clinical knowledge by asking questions of the prescribing physician? If so, this is a huge latent problem this hospital must overcome if they are to make any significant improvement in preventing medication errors let alone improving over all patient care and outcomes. As it turns out, there was no protocol for ordering coagulation studies when prescribing either coagulants or anticoagulant therapy. Thus, there is the latent problem of inadequate policies and procedures. There may have also been the latent problem of inadequate supervision for the physician ordering the Nitropaste. This physician had been practicing medicine for only two years. Could there have been a more experienced physician with whom she could have consulted? This may indicate a staffing pattern problem. What other latent problems do you think may exist in this case? The Level of Errors Using the AHRQ levels identified earlier, this is a Level 5 error. The error resulted in permanent patient harm the loss of her left arm. The Case Study of the Not So Busy Nurse It is a Sunday afternoon and two of the patients assigned to this nurse have been discharged. She only has two patients under her care for the remainder of the day shift. The nurse has 15 years of psychiatric experience. She works in a hospital on an acute psychiatric nursing unit. She is caring for a 45-yearold man, who has been admitted for treatment of schizophrenia. The patient has no other healthcare problems. Haldol (haloperidol) 5.0 mg is ordered intramuscularly every six hours as needed for agitation. She notes the patient is becoming quite agitated and in spite of other interventions, she appropriately determines he needs Haldol. The nurse proceeds to obtain five ampules of Haldol from the unit s stock medications. Each of the amupules contains 10 mg per ml, and each contains one ml of solution. She opens all five ampules and draws up two syringes of 2.5 ml of Haldol in each syringe. Upon seeing two syringes, the patient comments he s never had two shots before. She disregards the patient s comments as she thinks he s just agitated. She, then, proceeds to administer the Haldol to the patient in two injections. As a result of this dose of Haldol, the patient suffers permanent brain damage due to a medication encephalopathy. He now requires permanent institutional placement as he now has the mentality of a three-year old. Take a moment to answer these questions. What active and latent errors can you identify? Into which categories do these problems fit? (AHRQ Categories) Are You Prepared continued on page 13

13 March 2014 Ohio Nurse Page 13 Are You Prepared continued from page 12 What level of error occurred here? (ASHP Levels of Errors) Latent Errors One possible latent error is the availability of stock medications on the nursing unit a problem of inadequate policies and procedures. While this is often a convenience and may expedite obtaining medications for patients, it puts the nurse in the position of performing the pharmacy duty of dispensing medications. Being a Sunday afternoon, the pharmacy may have been closed, but should there be a pharmacist available? Should the pharmacy be open even on the weekends? Should there be a policy whereby only a house supervisor has access to stock medications? If the facility were using a medication dispensing system, perhaps this medication error would not have been made, as the dispenser would not dispense that number of Haldol ampules at one time. What other solutions would you suggest? Active Errors Look at how the order for Haldol is written with the dosage being 5.0 mg. Did the nurse read this as 50 mg due to the trailing zero after the decimal point? There is a saying, Always lead with a zero, but never trail with a zero. If a facility has adopted no trailing zeros as a policy, this constitutes a medication error in just the manner the order is written, let alone the fact the nurse administered ten times the ordered dose of the medication. This may also constitute a human problem on the part of the prescriber if they did not follow the policy of no trailing zeros. This is an experienced psychiatric nurse, who one would expect to be very familiar with a medication such as Haldol. In fact, this nurse stated she had given Haldol many times in her career. When questioned about the medication error, she stated she didn t know what she was thinking when she made the error. She said she and her co-workers had been having a conversation and she had continued to listen to the conversation while procuring the Haldol for this patient. While there is probably not a lack of clinical knowledge problem here, there is a human problem in following policy and procedures. The nurse was allowing herself to be distracted; thus, she did not meet the goal of administering the correct dose to the patient. There were a couple of red flags the nurse missed. First of all, she opened five ampules of medication. Shouldn t that have indicated to the nurse something was wrong? Most medications are packaged in the dosages we most commonly administer. Whenever one has more than one of something in your hands, we should double check what we are doing before we proceed. The nurse also drew up two syringes of the medication to administer. Isn t this another red flag? How often have you ever given two injections of the same medication at the same time? This is a rarely occurring event and the nurse should, again, have caught herself and stopped before proceeding. However, she did not. Thus, again, failing to follow policy and procedure, which is a human problem. The patient commented he had never received two shots previously. Here is yet another red flag and the nurse chose to disregard the patient s comments because he was in an agitated state. This constitutes a communication problem. What other active errors do you identify? The Case of the Too Busy Nurse It is a Sunday afternoon in a busy ICU in a large inner city hospital. The nurse is a seasoned veteran of 25 years of ICU experience. A 48-year old woman is admitted with a six month history of intermittent vaginal bleeding. The patient reports she was feeling cold and tired and her husband convinced her to go the hospital today. On admission, it is noted her hemoglobin is 2.6. An IV started in the ER is patent in the back of her right hand. The physician orders two units of packed red blood cells to be administered IV, each over a 1 to 2 hour period of time. The ICU nurses starts the first unit of blood via the IV in the right hand. Vital signs are monitored according to policy. They are stable and the patient experiences no transfusion reaction. The patient s blood pressure is 120/60, heart rate is 72, her respiratory rate is 16 and she is afebrile. While the first unit of blood is transfusing, the physician also starts a right internal jugular IV on the patient. The ICU nurse then starts the second unit of blood while the first unit of blood is still transfusing into the right hand IV line. The patient s vital signs remain stable; however, after a while, the nurse notices the patient s right hand is blue and swollen. The radial pulse is noted as being present, but the patient complains that the hand is numb and cold. The nurse notices the blood transfusion is running very slowly through the right hand IV line. The nurse removes the first unit of blood from the right hand IV line, and transfers it to the right jugular line. Then she takes the second unit of blood from the right jugular line and transfers it to the right hand IV line. She states she did this because the right hand IV was running so slowly, and she wanted to finish the first unit of blood before finishing the second unit of blood. Later that afternoon, shift nurse discontinues the right hand IV and notes the patient s right hand is dark purple in color, the skin is cold and the patient is complaining of pain in the hand. The afternoon shift nurse notifies the physician regarding the condition of the hand. The patient undergoes a fasciotomy of the right hand in an effort to relieve tissue pressures caused by compartment syndrome. However, this does not salvage the hand and she, subsequently, undergoes amputation of half of the index finger and total amputation of the middle, ring and little fingers. Further investigation into this matter reveals the nurse had been working double shifts of mandatory overtime. In the past five days, she had worked three overtime shifts for a total of 64 hours. The nurse stated they were always short staffed and failure to work mandated overtime would result in punishment and reprimands. This nurse, normally, worked the night shift and during this particular day shift, she had three other patients under her care. Take a moment to answer these questions. What active and latent errors can you identify? Into which categories do these problems fit? (AHRQ Categories) What level of error occurred here? (ASHP Levels of Error) Latent Errors: There is a staffing pattern problem in this case when a facility requires the amount of mandatory overtime as occurred here. Current recommendations include limiting the number of hours of nurses to twelve hours in a 24 hour period and 60 hours in a seven day period. This nurse had worked 16 hours on three out of five days and had worked 64 hours in a five day period, clearly more than current recommendations. There may be organization knowledge problems in this hospital. Why are they always short staffed and why are nurses required to work an abundance of overtime? Perhaps this hospital should review its orientation, staffing, recruitment and retention policies. Is this a problem only on this particular nursing unit or are these hospital wide problems? Are only a handful of nurses working the majority of the overtime shifts? Is the overtime being distributed evenly among the ICU staff? Could the hospital use the services of a supplemental staffing agency to fill vacant shifts? What other solutions can you suggest? What is the hospital s policy regarding a culture of safety? This may represent another organizational problem for this particular hospital. What other latent problems might exist here? Active Problems There are a number of instances of problems in following procedures or human problems in this case study. In one instance, the nurse is administering two units of blood at the same time. Never, if ever, does one ever administer two units of blood simultaneously. There was no order to administer the two units of blood at the same time; thus, there is a medication error. Another breach of procedure occurs when the nurse fails to discontinue the IV in the right hand when it clearly infiltrated. Perhaps the nurse failed to recognize the infiltrated IV because she was simply too exhausted from working so much over time. Plus, she normally worked the night shift and here she is working the day shift, a time she would normally be at home sleeping. 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14 Page 14 Ohio Nurse March 2014 Are You Prepared continued from page 13 Level of Error. Because the patient sustained permanent damage due to this error, this is a Level 5 error. To make matters worse, the patient was right hand dominant. The Case of the It s What the Doctor Ordered A 67 year old man, status post coronary artery bypass graft surgery, is admitted to the hospital to treat a substernal abscess he acquired postoperatively. The physician orders vancomycin hydrochloride 1000 mg IV every two hours to treat the wound infection. A wound culture is taken prior to beginning the vancomycin and results are pending. The nurse, who has five years of experience in medical-surgical nursing starts an IV in the patient s left arm and states she will be bringing his medication. Upon returning to the room with the vancomycin, the patient asks what the medication is. She tells him it is vancomycin. The patient states he thought he had received vancomycin previously, and he developed a raised red, itchy rash over his entire body and that he was told he was allergic to the medication. The nurse states, Don t worry. Your doctor wouldn t order anything for you to which you are allergic. This is what the doctor ordered for you. The nurse is paged to come to the desk to take a phone call, but before leaving the room, she proceeds to start the vancomycin via an IV infusion pump. Within minutes, the patient turns bright red, is itching all over and activates his call light. Upon entering the room, the nurse finds the patient on the floor, not breathing and without a pulse. She initiates resuscitation and calls for the Code Team. The patient was never able to be resuscitated and is pronounced dead. During the code, the vancomycin IV piggy-back was found to be completely empty. The tubing cassette had not been loaded into the infusion pump correctly and had been in a free flow mode. It is estimated the patient received the full dose of vancomycin within just a very few minutes instead of over a full hour (at a minimum). Take a moment to answer these questions. What active and latent errors can you identify? Into which categories do these problems fit? (AHRQ Categories) What level of error occurred here? (ASHP Levels of Errors) Latent Errors We don t know the policies and procedures of the physicians and pharmacy in this hospital, but both the physician and pharmacy contributed to the medication error made in this case by prescribing and dispensing a medication to which the patient was allergic. Perhaps if the hospital had been using a computer physician order entry system, it would have flagged the error before it even was sent to pharmacy. If the pharmacy had been following its procedures for screening for medication allergies, again, the error may have been caught before the medication was dispensed to the nursing unit. It is difficult to clearly identify whether these are human problems, communication problems or organizational problems. Active Errors There are human problems (failure to follow policies and procedures) in this case study when the nurse fails to listen to the patient s concerns about being allergic to the vancomycin. The nurse should have stopped and double checked the patient s allergies. If she had, she would have found the vancomycin allergy documented on the medical record. Another human problem (failure to follow procedure) exists when the nurse starts the vancomycin and immediately leaves the room to take a phone call. Perhaps she was distracted by the phone call, but shouldn t she have stayed at the bedside to monitor the IV infusion of vancomycin and make sure it was infusing appropriately before leaving the patient s room? Further, had she stayed to monitor the infusion, she would have seen the pump was not loaded appropriately (failure to follow procedure) and could have corrected the situation. This also constitutes a technical failure (either equipment failure and/ or poor design), as the pump did not sound an alarm when the cassette was not loaded correctly. Thus, when the nurse opened the roller clamp on the IV piggy back, it left the vancomycin in a free flow mode. The vancomycin was infused over just a few minutes versus the minimum of one hour. This constitutes another human problem (failure to follow a procedure) by infusing the medication over too short a period of time. What other active problems can you identify? Level of Error: Because this patient died as a result of receiving a medication to which he was allergic and it was infused over too short of a period of time, this is a Level 6 error. Suggestions for Error Proofing Medication Administration We are human and we continue to make errors. It is hoped we can reduce the number of errors we do make and reduce the damages to patients. Hopefully, as more healthcare facilities adopt a culture of safety and abandon the culture of blame, we can more fully recognize the amounts and types of errors made and can work towards eliminating as many as possible. As we discussed some suggestions for error proofing medication administration, think about your own practice. What have you done? What has your facility done to reduce errors? Do you work in an environment that promotes safety and views errors as a way to learn and grow? Or do you work in a culture of blame and reprimands? Ideas for Nurses Recognize medication errors and report all medication errors you do recognize. Review the patient s medications with respect to patient outcomes, possible medication duplications and drug interactions. Verify and assure all medication orders are complete before administering any medications. Verify the Seven Rights of Medication Administration. If there are any questions about any medication, the questions should be resolved before proceeding to administer the medication. It is better the patient receive the medication later, than receive a medication in error. Double check dosage and flow rate calculations with another person, especially if standard dose concentration or dosage charts are not available. Do not circumvent the medication delivery system by borrowing medications from one patient to administer to another patient. If there is a question about a large volume or number of dosage units, i.e., more than two tables, for a single patient, verify the order. If using infusion pumps, be sure to understand their operation. Talk with patients to ascertain they understand their medications and their indications. If a patient questions a medication, verify the order before administering the medication. Be aware of how many hours one is working within a shift or seven day period of time. Use only acceptable abbreviations; do not use any trailing zeros when transcribing dosages. Do not guess or assume what a prescriber meant to write in an order. If it is incomplete, contact the prescriber. Know your facility s policies and procedures regarding medication administration. With another nurse, double check any high risk or error prone medications and dosages before administrating. Stay abreast of new developments in error proofing medication administration and consider incorporating these developments in your practice. Work with the pharmacy to reduce or eliminate the need for floor stock medications. Ideas for Patients and Their Caregivers Make sure you understand what your medications are, what they look like, what they are used for, and how they are taken. Make sure you can read package labeling. If you can t, request the pharmacy label it in a manner in which you can read it. If you have great difficulty opening pill containers, request the medications be placed in containers you can open. If you can t read a prescription given to you by your prescriber, ask that they print it and spell out any abbreviations so that you can understand it. When obtaining your prescription from the pharmacy, be sure the label reads just as the prescriber ordered. There are many drug names that are similar and it is easy to mistake one medication for another. If a generic mediation has been used to fill your prescription, ask the pharmacist for a list of all brand and generic names for this medication. Make sure the pills or capsules look like the medication you usually take. If the pills appear to be a different color, question the pharmacist before taking any of the medication. Ask for and read printed information about your prescriptions. Know the side effects and what follow up test may be necessary while taking your medications. Know how long you will need to be taking the medication. Know what to do if it seems the medication is not working for you. Know how and when to take the medication. Tell your prescriber, nurse and pharmacist about any over-the-counter medications, vitamins, mineral and/or herbal supplements you take. Keep a list of all medications, including over-thecounter and supplements, and allergies and take this list to any medical appointment. It is also a good idea to keep this list in your wallet in case of an emergency. If you find an error has been made, bring it to the attention of your prescriber, nurse and pharmacist. If anything doesn t seem right to you, ask, ask, ask! High Tech Solutions Borrowing from grocery store technology, many facilities have begun to use bar code readers. The readers are coded with the patient s identification wristband, and the patient s prescribed medications. If an error is about to occur, such as the wrong dose, the bar code reader alerts the nurse because the bar codes will not be a match between the medication and that particular patient. Of course, bar code readers are only good in preventing errors if we use them correctly and consistently. Plus, all data such as patient identification and prescribed medications have to be entered into the system correctly. The Veteran s Administration Medical Centers were some of the first healthcare institutions to use bar code readers, and they have had great success in reducing medication errors. Computerized physician order entry (CPOE) systems are also gaining in popularity. Instead of the physician hand writing the order, the physician simply enters the medication order directly into a computer. This eliminates any hand writing legibility issues as well as any transcription errors that are likely to occur. Furthermore, the orders are sent directly to the pharmacy for quicker dispensing of the medications to the nursing units. An added benefit of some computerized physician order entry systems is that if the prescriber makes an error, say in dosage, it is red flagged at the time the order is being written. The prescriber would be alerted to the error, and then has an opportunity to correct the error before it is sent to the pharmacy. Or, if the prescriber desires to order a dose that is out of the standard range, they have to go into an override mode in order to proceed with that particular medication prescription. Many computerized physician order entry systems will not allow any incomplete orders to be sent to the pharmacy. If an order is not complete, the missing information is highlighted and again, the prescriber has an opportunity to complete the order. Expense and creating such complex systems are two major drawbacks to the computerized physician order entry systems. It will be interesting to see these systems evolve as we gain more and more technology to handle the complex issues of medications. Every day new medications are entering the market. Patents expire on existing medications, only for us to see a flood of new generics for that medication. We discover new uses for medications. How do we, as healthcare professionals, keep up with this massive inflow of information? In some institutions, healthcare professionals are supplied with hand held computers such as PDA s or Blackberry devices into which medication information has been downloaded. The prescriber can, then, consult the device and obtain information regarding the medication they are about to prescribe. Of course, this technology is only as good as the extent to which it is used. If a prescriber doesn t consult the information, they may still find they can make errors. The quality of information downloaded into the device itself is also an issue. Is it the most up-to-date information? What is the source of the information? In some instances, facilities have established their own formulary on-line that can be consulted by any healthcare professional. Again though, any of these devices are expensive as well as one has to take into consideration the cost of maintaining on-line information. Some facilities are using medication-dispensing machines, similar to vending machines. These machines dispense only the doses, routes and medications ordered for the patient, and only at the time the medication is needed. Usually, the patient s medical identification number is entered into the machine to obtain the needed medications. If another medication is needed, there are override methods for obtaining stat medications or one time only medications. This is relatively new technology. It is not error-free at this point, but it will be interesting to see how this technology evolves in the future. Low Tech Solutions Cost certainly is an issue when any new technology is mentioned. Not every facility has the budget for the technological advances that are being made at this time. However, there are many things that can be accomplished without the aid of the latest technological wonder. Let s explore just a few of these low tech items. Remember the Woman and Children s Hospital of Buffalo? They did not have the money to explore a computerized physician order entry system. They simply redesigned their physician order sheet and had significant improvement in delivery medication to patients and minimizing errors. What forms might your facility consider redesigning to help error proof medication administration? Could there be changes to the medication administration record that would assist the nurse and at the same time, minimize errors? Think about all the times you ve said to a colleague, If our medication sheet only had o n it, it would be so much easier. Pay attention to those types of comments, discuss them at staff meetings. You might just have a great solution to an on-going problem! Are You Prepared continued on page 15

15 March 2014 Ohio Nurse Page 15 Are You Prepared continued from page 14 What protocols, policies and procedures do you need? If there are consistent problems occurring with certain types of medications, does your facility need a protocol to guide the administration of that medication to minimize errors? Look at the types of medication errors occurring in your facility or on your unit. Again, discuss these with your colleagues, physicians, and pharmacists. What solutions can be developed? If you are struggling with certain error prone medications, chances are so are others. What abbreviations are being used in your facility? Which abbreviations are contributing to errors? What is on your acceptable abbreviation list? What protocols, policies and procedures are in place guiding the practice of overtime hours in your facility? Remember the new thinking in healthcare, adopted from the trucking and airline industries, is that no one be allowed to work more than twelve hours in one day and none more than sixty four hours per week. Is there a plan to distribute overtime evenly and fairly among all staff? Do you always say yes to overtime, when perhaps you should not? Has your facility adopted a Culture of Safety, or are your employer and colleagues still playing the Blame Game? While you, as an individual, may not be able to change the culture of your employer single handedly, you can role model and incorporate a culture of safety in your own daily practice and in mentoring and nurturing colleagues. As we saw earlier at Women and Children s Hospital of Buffalo, the Culture of Safety began with the leadership of the facility. Without that leadership stance, they probably would not have been as effective in reducing the number of medication errors. If an online drug formulary is not available to you to consult regarding medications, from where do you obtain drug information? Does your unit have an up-to-date drug reference book? Or is the PDR (Physician s Desk Reference) from 1978? Do you have access to nurses drug references? Are they up-to-date or the latest editions? Do you have access to a pharmacist to consult with regarding medications? Do you consult nurse colleagues with your questions about medications? Do you ask question of the prescriber when you don t understand an order or an indication for a medication? Or do you work in a culture that penalizes nurses for bothering physicians too much? Does your pharmacy supply you with ample information about medications? For example, does your pharmacy routinely label a generic medication as an equal substitute for the name brand medication? If the order, normally, would have been filled with one tablet, but due to supply issues, the pharmacy had to send three tablets, do they label the substitute as such? If it is a new medication in the facility s formulary, is information sent to the nursing unit along with the new medication? Pharmacists are the experts regarding medicines. Are they supplying you with the information you need to deliver medications to patients as efficiently and error-free as possible. How could the pharmacy assist you? Are you asking for those services from the pharmacy? When new medications, protocols or medication delivery devices are instituted, do you receive adequate inservice education? Is it offered? Do you attend the session? Are the sessions available on videotape, DVD or on line if you were not able to attend a live session? If you are not able to attend in-service sessions, are the instruction manuals for new devices available for you to consult? Do you give your honest input when education department personnel ask for topics of interest and/or need? What do you do to keep yourself current in practice? Costs of Medication Errors: In the 2003 Medicare Modernization Act passed by Congress, the Institutes of Medicine were charges with the task of reducing medication errors health system wide. In their report issued in 2007, the Institutes of Medicine estimates there are 400,000 adverse medication events that occur annually in hospital settings. An adverse medication event is defined as an injury due to a medication. Each adverse medication event adds an estimated $5, to that patient s care. If there are 400,000 such events, that adds an estimated $3.5 billion (in 2006 dollars) annually to healthcare. This is for hospitalized patients only. It is estimated there are 800,000 adverse medication events that occur annually in patients in long term care facilities. With the current economic climate as well as the possibility of Medicare and/or Medicaid going broke, strictly from a financial aspect, we need to eliminate medication errors and adverse effects, let alone the effects it has on patients and staff. What other items can you think of that would help you in your daily practice and error proof medication administration? What will medication administration systems look like in the future? Hopefully, we may someday achieve a nearly error free system. Hopefully this module has stimulated your thinking about medication errors and given you pause to consider your own nursing practice. Are You Prepared to Prevent Medication Errors? Post-Test and Evaluation Form DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question. The evaluation questions must be completed and returned with the post-test to receive a certificate. Name: Date: Final Score: Please circle one answer. 1. The IOM study of 1999 helped us realize the scope of medication errors. 2. Competent healthcare providers do not make mistakes. 3. Errors are opportunities to fix system problems. 4. A key step to adopting a Culture of Safety is that leadership assumes an active role in the cultural change. 5. The Five Rights of Medication Administration are goals, not procedures. 6. The correct indication and correct documentation, added to the Five Rights complete the Seven Rights of Medication Administration. 7. Interruptions and distractions do not contribute to medication errors. 8. Knowing why a medication is ordered or indicated may help reduce medication errors. 9. Nurses are so used to correcting errors, we often do not even recognize them. 10. Becoming familiar with your employer s medication error tracking methods will help you recognize errors when they occur. 11. Human problems may include a lack of clinical knowledge. 12. Communication problems may include written or verbal communication. 13. Staffing problems may contribute to medication errors. 14. A level 0 medication error is sometimes called a near miss. 15. A level 4 error results in the patient s death. 16. Trailing zeros should always be used when indicating doses of medication. 17. Nurses don t need to listen to patient s concerns about medications. 18. It is all right to work more than sixteen hours in a twenty four hour period. 19. Nurses should not work more than sixty four hours in any seven day period. 20. It is better to administer a medication on time and resolve any question you have later. 21. It is OK to borrow medication from one patient to use for another patient. 22. Always lead with zeros, but never trail with zeros in indicating doses. 23. There are many things, including maintain an up to date list of medications, patients can do to help prevent medication errors. 24. Healthcare has borrowed ideas from other industries in error proofing medication administration. 25. Cost is a drawback to using some high tech solutions for error proofing medication administration. 26. Any solutions, whether they are high tech or low tech, are only as good as the extent they are used. Evaluation 1. Were you able to achieve the YES NO following objectives? a. Identify the Seven Rights of Yes No Medication Administration. b. Identify types of problems and Yes No level of errors that can occur in medication administration. c. List strategies nurses might use Yes No to assist in error proofing medication administration. d. List strategies patients might Yes No use to assist in error proofing medication administration. 2. Was this independent study an Yes No effective method of learning? If no, please comment: 3. How long did it take you to complete the study, the post-test, and the evaluation form? 4. What other topics would you like to see addressed in an independent study?

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