1. Mee, Cheryl L. RN, BC, CMSRN, MSN

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When I was a young nurse, I failed to catch a mistake someone else had generated and administered the wrong I.V. solution to a patient. I felt so ashamed afterward that I considered leaving nursing. Fortunately, the patient wasn't harmed and I learned from my error. Although I alone took the heat, a closer look at hospital processes then could have improved practices and helped all the nurses administer medications more safely.


At about the same time as my error, this journal launched the Medication Errors department by Michael Cohen. A pharmacist and founder of the Institute for Safe Medication Practices (ISMP), Mike has devoted his career to medication safety. Today Mike and other health care professionals at ISMP spread the word about error prevention to people involved in all stages of medication therapy. In Medication Errors (see page 12), they alert you to confusing drug names, look-alike labels, and equipment hazards.

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The ISMP contacts manufacturers whose products pose risks and presses them for improvements. It also backs the use of systems such as bar coding, smart pumps, and computer prescriber order entry to enhance the defense against errors.


We all understand how a rushed nurse with an unreasonable patient load could grab a medication vial and misread the label. Fearing disciplinary action or a lawsuit, she might be tempted to keep her mistake under wraps. But this would only increase the danger. A practice environment that discourages reporting not only casts a shadow of shame on nurses, but also perpetuates unsafe practices. Reporting and investigating errors and near misses are the only way to identify and solve problems plaguing the medication process.


You're not the problem; you're the last line of defense against medication errors. Recognizing this, the ISMP has adopted the credo, "Stop blaming the nurses." They consider punitive-free reporting the only way to root out sources of error embedded in the medication delivery system.


At long last, health care institutions are catching on. More and more employers are supporting nurses who report errors and ferreting out trouble spots that contribute to them. Any organization that's serious about keeping nurses and protecting patients must adopt and maintain nonpunitive reporting protocols.


Thanks to the dedication of such groups as the ISMP, health care organizations are rethinking how they handle medication errors. And as the last line of defense for patients, you're finally starting to get the support you need to practice more safely at the bedside.


Cheryl L. Mee



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