ISMP Call to Action: Resist the Land of Not Yet and Distribute FREE NurseAdviseERR® to All Nurses

In addition to the ISMP Medication Safety Alert!, ISMP publishes NurseAdviseERR, a free monthly newsletter specifically for frontline nurses (Figure 1). This 4- to 5-page, peer-reviewed newsletter is an abbreviated version of the ISMP Medication Safety Alert! covering some of the high-priority medication safety issues discussed in this newsletter, but tailored for nurses. NurseAdviseERR is designed to meet the unique medication safety and educational needs of nurses who receive medication orders, administer medications, and monitor the effects of medications on patients. The publication was launched with educational grants in 2003 due to our deep concern that frontline nurses were not being made aware of significant medication errors reported to the ISMP National Medication Errors Reporting Program (ISMP MERP), along with the recommended strategies to prevent errors. ISMP continues to receive educational grants from various companies and foundations to offer the newsletter free to all nurses, as well as medication and patient safety officers, quality and risk management staff, faculty who provide nursing education, and nursing students.

Although we are in our seventeenth year of publication of NurseAdviseERR, we are worried that many US hospitals are not distributing this free resource to nurses, thus missing a key opportunity to involve nurses as an integral safety partner to solve the most formidable medication safety challenges. The predominant goals of NurseAdviseERR are to arm nurses with critical medication safety information and to bring the nursing voice to an interdisciplinary team to assist hospitals in understanding the underlying causes of medication errors and redesign their systems to prevent patient harm. And, the nursing voice can be quite powerful, both within the organization and nationally!

For example, in 2010, ISMP conducted a survey via NurseAdviseERR during which more than 17,500 nurses made it abundantly clear that the Centers for Medicare & Medicaid Services (CMS) rule requiring administration of all medications within 30 minutes of their scheduled time was often impossible to follow, leading to serious, unintended consequences. Nurses spoke up about feeling compelled to take unsafe shortcuts to comply with the rule, including removing medications from an automated dispensing cabinet (ADC) via override, documenting administration at the scheduled time but actually giving the medication early or late, failing to use barcode scanning to avoid documentation of late administration, borrowing medications from other patients, skipping independent double checks, and many other risky shortcuts. The nurses’ input on this important medication safety topic unquestionably served as a catalyst to national changes. In 2011, CMS eliminated the longstanding 30-minute rule for all scheduled medications, highlighting our effort. Now, hospitals are expected to classify scheduled medications into categories that reflect appropriate timing for administration that balances patient safety with the need for flexibility in work processes.

When nurses are consistently provided with information about risks that are causing potentially harmful errors and are given a chance to speak up, they are a powerful group. If nurses in your organization are NOT receiving and reading NurseAdviseERR, they may have MISSED out on learning about these key risks and more since January 2019.

• Concern about wrong patient errors between the mother and her newborn due to recent changes in the newborn naming convention that embed the mother’s first name into the newborn’s temporary name (prior wrong patient errors were more often between newborns with similar/same names) 

• Failed insulin administration via pen devices in the home because patients have not been taught to remove the inner needle cover on a standard pen needle prior to injection (safety needles with retractable needle covers are not used in the home)

• RITUXAN HYCELA (riTUXimab/hyaluronidase) and HERCEPTIN HYLECTA (trastuzumab/hyaluronidase-oysk) must be administered subcutaneously despite unusually large dose volumes well over the usual limit of 2 mL; these large volume subcutaneous doses risk being administered intravenously (IV)

• Optional adhesive cover (without medication) that can be applied over a cloNIDine patch has been mistaken as the actual cloNIDine patch and applied alone

• Simulation products used for training purposes that have made their way into patient care areas and were mistaken as the real medications or solutions

• A neuromuscular blocking agent administered to an unventilated patient, which was associated with the unsafe retrieval of a medication from an ADC (by override) after typing just two letters of a drug name into the search field, selecting the wrong medication from the screen, and several other systematic safety failures

• Ongoing fatal cases of intrathecal administration of IV vinca alkaloids, which led ISMP to call upon the US Food and Drug Administration (FDA) to remove instructions for preparation and administration of vinca alkaloids by syringe from product labeling, in favor of safer dilution in a minibag

• Mix-ups between epidural analgesia and IV antibiotics in labor and delivery areas

• Errors due to incorrect interpretation of glucometer results due to codes used to present the results

• Announcement of updated ISMP guidelines for the safe use of ADCs and electronic communication of medication-related information, along with an invitation to comment on updated draft guidelines for smart infusion pumps

Where else can frontline nurses get information like this?

Healthcare is an industry that professes to be racing towards high reliability; but rather than nurturing a healthy preoccupation with failure, we have a natural tendency to be too optimistic and overconfident in our abilities and systems. We tend to view errors that happen elsewhere as irrelevant in our own work, so the stories of risk and errors illustrated in NurseAdviseERR may not seem worthy of attention. We were reminded of our natural tendency to be overconfident in our abilities and systems when an ISMP staff member recently shared the following message she had seen flash across the television screen between shows (source: Chuck Lorre Productions, #545):

I don’t know about you, but I’ve been spending most of my time in the land of Not Yet. If you are unfamiliar with it, Not Yet is a happy place where all the bad things that seem likely to occur have not happened… yet. I like to think of it as a shimmering, shivering soap bubble whose fragile beauty is only made greater by the knowledge that it will soon burst, making way for the darker realm of You Got To Be Kidding Me.

But not now.

Not Yet.

And yes, I would love to say Not Ever, but that place doesn’t exist.

ISMP Call to Action

ISMP is calling on all medication safety leaders to resist living in the land of Not Yet and to provide nurses with a practical tool like NurseAdviseERR to learn about emerging and ongoing risks that are clearly relevant to all hospitals. Please don’t assume that nurses in your organization are receiving this publication or getting a copy of this newsletter. In late 2018, all current subscribers to NurseAdviseERR were asked to re-subscribe to accommodate a new customer management system. Many previous subscribers have done so, but others may have overlooked this step and may not realize that they are no longer receiving the newsletter.

Please talk to your nursing staff to find out if they are currently receiving NurseAdviseERR. Keep in mind—even if nurses currently receive the ISMP Medication Safety Alert!, it is crucial to also provide them with NurseAdviseERR, which presents medication safety issues from a unique nursing perspective. NurseAdviseERR also includes articles unique to nurses that do not appear in the ISMP Medication Safety Alert!   

If nurses are not currently receiving NurseAdviseERR, forward this link to them to subscribe: www.ismp.org/node/138. The recommended subscription process is as follows:

• ISMP encourages one or two coordinators from each facility to subscribe to the newsletter. Each month, coordinators will receive an email directing them to log in to their account to access the latest newsletter. Coordinators will need to download a PDF version of NurseAdviseERR (look for a link to “Download PDF” in the right corner of the webpage) and redistribute the PDF version of the newsletter to all other nurses within their organization. Coordinators should NOT redistribute the original email, as only subscribers will be able to access the newsletter online.

• Individual nurses can also subscribe on their own but do not have permission to redistribute the newsletter. Having an individual subscription will allow nurses to view NurseAdviseERR at any time, in any location, on any device.

• Any healthcare professional, educator, or student having difficulty subscribing to the newsletter without getting a subscription fee may checkout with code NURSE2019 to receive the newsletter for free. 

History has shown that a medication error reported in one organization is likely to occur in another. It would be foolish to not utilize easily accessible information provided by others who have already experienced errors and are working towards improving their systems. NurseAdviseERR provides the lens for nurses to accomplish this. It costs nothing to use, but its value could be priceless.