Nursing morbidity and mortality conferences.

A 50-year-old male patient presented to the emergency department with a diagnosis of new onset atrial fibrillation with rapid ventricular response. He was started on a diltiazem drip to control his heart rate and was subsequently transferred to the intensive care unit (ICU). Upon arrival, he experienced a severe bout of hypotension that was to be treated with a saline bolus. The nurse caring for the patient asked another nurse, who was helping with the admission, to get a bag of saline while she left to obtain an intravenous pump for the diltiazem infusion. Upon her return, the nurse proceeded to rapidly infuse what she thought was saline. However, the patient received an inadvertent bolus of diltiazem, causing a severe bradycardia that required multiple doses of calcium and a temporary pacemaker. The above vignette actually happened. The error occurred despite adequate staffing, experienced nurses, a correct diagnosis, and appropriate therapy. In this case, the mistake occurred because the nurse caring for the patient made the decision to leave the bedside to get a necessary piece of equipment, the intravenous fluid with the diltiazem was not clearly marked, and communication was inadequate between the 2 nurses caring for the patient. The situation, like thousands that occur in hospitals every day, illustrates the vulnerability of critically ill patients and the dire consequences that can occur when communication breaks down. The current realities documented in many hospitals (inadequate nurse staffing, inexperienced medical and nursing staff, fatigued physicians and nurses, and outdated technology) make unfortunate errors all too likely to occur. But even when all of these problems are adequately addressed, errors will still occur. The care of critically ill patients is an all too human enterprise. Alerting the Public The landmark white paper from the Institute of Medicine (IOM), “To Err Is Human: Building a Safer Health System,” exposed the challenges that exist to patient safety in today’s hospital environment. Among other things, the authors noted that errors are often the result of a multitude of contributing factors that are difficult to envision or predict in advance. Preventable adverse events are a leading cause of death in the United States. In any 1 year, deaths from medical errors exceed those due to motor vehicle accidents, breast cancer, or AIDS. Extrapolating results from previous studies, the IOM report estimated (and possibly underestimated!) that somewhere between 44 000 and 98 000 Americans die annually in hospitals as a result of medication errors alone. The total costs of these errors in terms of lost income, lost household production, disability, and healthcare costs is staggering. And the problem extends beyond the hospital into other healthcare venues not examined as rigorously as hospitals, such as outpatient surgery centers, physician offices, and pharmacies. More than 70% of adverse events are preventable, with the most common types being technical or treatment errors (44%), diagnosis-related errors (17%), failure to prevent injury (12%), and errors in the use of a drug (10%). What types of errors do nurses and physicians commit? Transfusion errors, wrong-site surgery, restraint-related injuries, falls, and infections from intravenous lines are among the most frequently cited nonmedication-related errors. Medication errors have been examined most closely as a cause of preventable adverse events. They can occur during prescribing, dispensing, administration, or monitoring, as well as be the result of systems failure. Factors influencing medication administration are often defined as the “right” drug, to the “right” patient, at the “right” time, in the “right” dose, and via the “right” route. However, these “5 rights” fall short in addressing the more global picture of medication error because they focus on the nurse’s individual perforEDITORIAL