Common Nursing Errors/Mistakes: As experienced nurses, we do nursing procedures every day and they become routines over time. But do you know that there are common nursing procedures that sometimes we do wrong?
Common Nursing Errors/Mistakes
1.Patient Falls
Every single patient—whether young or old, post-op or not — has the potential to suffer a fall-related injury while hospitalized. Patients may fall when they need to go to the bathroom or if they simply get out of bed. Patients are often eager to regain independence and attempt to move without assistance before they are ready.
Every fall has the potential to cause serious injuries, which will delay the patient’s recovery, cause additional complications, and create legal problems for the hospital. Nurses can reduce the risk of fall-related nursing mistakes by taking the following precautions:
- Identify the patients most at risk of falling while keeping in mind that any patient could potentially fall
- Frequently check on all patients, especially high-risk patients
- Ensure patients have everything they need within arm’s reach
- Ensure patients know where the call button is and assure them that nurses are available for assistance
2.Improper Documentation
When patients’ information is recorded incompletely or incorrectly, the care needed may not happen. Types of documentation errors include not recording (or recording inaccurate details about):
- Patient histories
- Medications given or stopped
- Nursing actions
- Instructions for care going forward
3.Medication Administration
1. Not all oral medications can be crushed.
Nurses usually crush medications into powdered form so it can be administered via NGT. But according to Royal Pharmaceutical Society (2011) crushing an oral solid dosage form may have a negative impact on the stability of the drug substance. If an enteric coating, which protects a drug from the acidic environment in the stomach, is removed by crushing the tablet, the in vivo drug degradation will increase, with less drug available to produce the desired clinical effect. Nifedipine is an example of a drug that is highly light sensitive after tablets have been crushed.
Extended-release products are formulated to release the drug over an extended period of time. Remember, their usual product names have CR, ER, LA, SR, XL or XR.
Another example is the oral tablet called ACCUPRIL (quinapril). Crushing an Accupril tablet and dissolving it in water for enteral administration allows the carbonate to increase the pH of the solution, causing the drug to rapidly degrade into a poorly absorbed metabolite, (Institute for Safe Medication Practice, 2010).
If you happen to have a patient with NGT and has any of these medications, discuss with the physician and suggest a different formulation compatible for NGT administration. You may also inquire from your pharmacist which medication formulation he/she can recommend.
2. Enoxaparin is kept at room temperature, not on fridge or freezer.
Nurses usually store enoxaparin at the refrigerator. Drugs.com suggests storing enoxaparin at room temperature, between 15- and 25-degrees C. Store away from heat, moisture, and light.
3. Mannitol should not be administered with crystals.
Drugs.com recommends inspecting Mannitol bottle for crystals prior to administration. If crystals are observed, the container should be warmed by appropriate means to not greater than 60°C, shaken, then cooled to body temperature before administering. If all crystals cannot be completely dissolved, the container must be rejected. Administer intravenously using sterile, filter-type administration set.
Electrolyte-free Mannitol Injection should not be given conjointly with blood. If it is essential that blood be given simultaneously, at least 20 mEq of sodium chloride should be added to each litre of mannitol solution to avoid pseudo agglutination.
4. Medications, as much as possible, should not be crushed using mortar and pestle.
Nurses usually crush tablets using mortar and pestle since they are the most convenient tools to convert tablet to powdered form. However, Institute for Safe Medication Practice (2010) do not recommend crushing tablets using such tools since there is the possibility of powder loss. Example: about 25% of aspirin was lost when a mortar and pestle was used to crush tablets prior to suspending the powder in water.
5. As much as possible, do not split tablets using a knife or pill cutter. If possible, prescribe medication with the exact dosage.
According to ISMP (2010), splitting tablets with a splitting device, may result to tablet pieces that are not the same size, and whose weight can vary by 15% to 20% of the theoretical weight i.e. half the weight of the intact tablet.
4.Hospital-Acquired Infections (HAIs)
Hospitals are supposed to be meticulously clean, healthy places, yet about one in every 31 hospitalized patients has at least one HAI at any given time according to studies. Many types of HAIs can affect patients, including:
- Surgical site infections (SSIs)
- Ventilator-associated pneumonia (VAP)
- Catheter-associated urinary tract infection (CAUTI)
- Central line-associated bloodstream infection (CLABSI)
Patients may acquire these types of infections while still in the hospital, or symptoms may develop shortly after discharge. To avoid these nursing errors, nurses need to strictly follow all hygiene, cleaning, and sterilization protocols.
5.Airway Management & Suctioning
1. Do not Instill normal saline Regularly in the endotracheal tube
As nurses, we have this practice of instilling normal saline for about 1-2 cc, because we believe that it may loosen secretions, increase the number of secretions removed, and aid in the removal of tenacious secretions. However, there is insufficient evidence to support this premise. Always use if needed not as Routine until an alternative solution is made available.
According to American Association of Respiratory Care (AARC), routine use of normal saline instillation may be associated with the following adverse events: excessive coughing, decreased oxygen saturation, bronchospasm, dislodgement of the bacterial biofilm that colonizes the ETT into the lower airway, pain, anxiety, dyspnea, tachycardia, and increased intracranial pressure.
2. Routine suctioning is not a good habit.
The reason for this is because there is considerable risk with using “routine” suctioning. In a literature review by Hahn (2010), it recommended that ETS should be performed as infrequently as possible—yet as much as needed.
3. Avoid using catheters larger than one-half the diameter of the airway.
Nurses have the tendency to use suction catheter which are readily available without considering the diameter of the endotracheal tube. Studies Say, if a suction catheter is too large for the ETT, and/or there is too much vacuum pressure, massive atelectasis may occur. Therefore, the general recommendation is to use a suction catheter that has an external diameter less than 50% of the size of the ETT inner diameter.
4. Minimize the frequency and duration of suctioning when patient is on positive end-expiratory pressure (PEEP) greater than 5 cm or continuous positive airway pressure (CPAP).
Small suctioning-induced changes may have profound effects on these marginally oxygenated patients.
5. Close suction is more recommended that open suction.
According to AARC (2010), the use of closed suction is suggested for adults with high FIO2, or PEEP, or at risk for lung decruitment, and for neonates. Endotracheal suctioning without disconnection (closed system) is suggested in neonates.
6. Use of shallow suction is suggested instead of deep suction
The drawback with deep ETS is that there is some degree of mucosal injury and the potential for bleeding, as well as the possibility of vagal stimulation and bradycardia, (Hahn, 2010).
7. Airway obstruction management has an algorithm. Do not panic!
Hosking et al have proposed a practical algorithm for the management of airway obstruction. Hyperinflation of the ETT cuff for a short period of time, followed by reevaluation by a FOB (to prevent tracheal mucosal injury) and the maneuver to rotate the ETT to move the bevel away from the tracheal wall are incorporated in the algorithm of the steps taken for airway obstruction in an intubated patient.
8. Cuff over-inflation
The inability of nurses to determine endotracheal tube cuff pressure by the traditional standard method of palpation of the pilot balloon has been addressed according to Johnson & Lehman (2012). The use of pressure manometer or noninvasive manometers can be used to properly measure cuff-pressures.
9. Don’t bag too much with manual resuscitator.
When using a bag valve mask, provide a volume of 6-7 mL/kg per breath (approximately 500 mL for an average adult) to the patient. Bosson & Mosinefar (2015) recommends that for a patient with a perfusing rhythm, the nurse should ventilate at a rate of 10-12 breaths per minute. During cardiopulmonary resuscitation (CPR), give 2 breaths after each series of 30 chest compressions until an advanced airway is placed. Then ventilate at a rate of 8-10 breaths per minute. Give each breath over 1 second. If the patient has intrinsic respiratory drive, assist the patient’s breaths. In a patient with tachypnea, assist every few breaths.
10. Using alternative sites for testing blood sugar
It is commendable but may cause “lagged” results.
Blood testing are usually done on patient’s fingertips but there are other alternate sites including: earlobe, upper arms, forearms, hands, thighs, and calves.
However, alternate test sites are not all the same. With all meters, routine testing on an unrubbed forearm, upper arm, thigh or calf gives a test result that is 20 to 30 minutes old. According to an article by BD (n.d) the fingertips and the palm hold the most recent ‘memories’ of a patient’s blood glucose. On the other hand, lagging test sites such as the forearm or thigh is the blood glucose of the patient around 20 to 35 minutes ago.
6.Needle-stick Injuries
While most types of medical errors affect patients, some affect healthcare workers. Nurses are vulnerable to needle-stick injuries, also known as sharps injuries. A needle-stick injury occurs when a used needle punctures the skin accidentally. For instance, you may have just used a needle on a patient and then accidentally pricked your own skin with it before you could dispose of it properly.
While the pinprick itself isn’t dangerous, it may introduce various illnesses into your bloodstream. Needlestick injuries can expose nurses to blood-borne pathogens like HIV, hepatitis B, and hepatitis C.
All needlestick injuries require immediate action; nurses must assume the worst will happen and act accordingly. The area should be thoroughly scrubbed with soap and water and “milked” to encourage bleeding. The sharps injury must also be reported to the charge nurse or another supervisor immediately.
To reduce the risk of sharps injuries, remember that gloves won’t protect you from them. Follow all safety precautions to the letter. Never try to re-cap a used needle, and place all used needles into an approved sharps container immediately after use.
REFERENCES
- 15 Common Mistakes during Nursing Procedure retrieved from https://rnspeak.com/nursing-skills/common-nursing-procedures/
- Carayon, Pascale & Gurses, Ayse. (2008). Nursing Workload and Patient Safety—A Human Factors Engineering Perspective. Journal of Bahrain Medical Society 2018/03/30 doi: 10.26715/jbms.1_26032018
- Athanasakis, Efstratios. (2012). Prevention of medication errors made by nurses in clinical practice. Health Science Journal. 6. 773-783.
- Croke, Eileen. (2003). Nurses, Negligence, and Malpractice: An analysis based on more than 250 cases against nurses. AJN The American Journal of Nursing. 103. 54-63.
- Smith, Timothy. (2010). A Policy Perspective on the Entry into Practice Issue. Online Journal of Issues in Nursing. 15. 10.3912/OJIN.Vol15No01PPT01.
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