I RECENTLY HAD THE opportunity to participate in a national safety summit at the Institute for Safe Medication Practices (ISMP). It was an exciting experience and very different from my daily bedside ED nursing duties. At the time, I was just beginning to branch out beyond the bedside to participate in unit-based and hospital-wide professional initiatives, so the summit shed even more light on the professional side of nursing. I hope that sharing my experience will encourage other bedside nurses to seek out and be open to personal and professional growth opportunities.
The Magnet® influence
Christiana Care Health System's (CCHS's) Christiana Emergency Department has been my home for the last 28 years. It's a high-volume, high-acuity Level I trauma center located in Newark, Delaware. Through its efforts to achieve Magnet® designation, CCHS has demonstrated its commitment to nursing excellence and high-quality patient care. When my hospital achieved Magnet designation in 2010, many positive changes were put into effect that benefited nurses and facilitated opportunities for professional growth. One example was the development of a clinical ladder, which was designed to encourage commitment to nursing professionalism.
The Magnet culture challenged us to explore and participate in professional opportunities to improve the patient experience. Through shared decision making, clinical nurses have a voice in problem solving and the power to effect change. This approach has opened the doors and uncovered a whole new aspect of nursing that wasn't well known to nurses in the pre-Magnet era. Since our Magnet designation 7 years ago, many more nurses have branched out from the bedside to participate in unit-based and systemwide professional activities. My experience participating in the ISMP summit is one example.
The vice president of Emergency and Trauma Services at Christiana Care, who was familiar with my involvement in quality and safety initiatives in the ED, asked me to consider attending a national summit on I.V. push medication safety organized by ISMP. The summit brought together an interdisciplinary group of healthcare experts in the United States to exchange information and explore ideas about barriers that may impede safe I.V. push drug administration. I was somewhat familiar with ISMP's work and knew this summit would be an experience that I couldn't pass up. (See ISMP: Dedicated to error prevention.) I was excited to represent our ED at the summit.
The ISMP engagement
ISMP has received and published numerous I.V. push-related error reports involving patient injury obtained through the ISMP National Medication Errors Reporting Program (MERP), a voluntary, confidential program for collecting information about medication errors and near-misses. They noted that while much emphasis has been placed on the improvement of I.V. infusion safety, there was a limited amount of published evidence and a lack of standardized safe practices guidelines associated with administration of drugs given I.V. push.
In the distant past, I.V. push medications were administered by physicians. The development and introduction of disposable I.V. catheters and tubing led to an explosive growth in the use of I.V. therapy, and the responsibility for administering I.V. medication at the bedside was transferred from physicians to nurses. By the 1990s it was estimated that more than 85% of hospitalized patients received some sort of I.V. therapy.3
Typically, new nurses review I.V. push injection technique during orientation. The problem with this method is that orientation content is specific to each institution, or even particular departments. This approach leads to a variation in knowledge and skills. There is often a lack of standardized practice guidelines across hospital systems and even units in the same hospital that can lead to multiple patient safety risks.
Because of this lack of standardized practices, the limited amount of evidence-based information about I.V. push medications, and I.V. push error reports received through MERP, ISMP identified the need for I.V. push medication guidelines as an area for growth. ISMP recognized that it was imperative to provide healthcare professionals with relevant information to assist them in identifying and managing risks associated with I.V. push medications.1
ISMP assembled an interdisciplinary team of 56 experts from across the country to explore the challenges and to brainstorm ways to simplify and standardize the process of I.V. push medication administration. Participants included representatives from hospitals and other frontline healthcare providers, professional organizations such as the Infusion Nurses Society and the Emergency Nurses Association (ENA), regulatory agencies such as the FDA, and pharmaceutical product vendors. These expert stakeholders in medication safety worked together to offer evidence-based error reduction strategies that work. All participants were volunteers and received no compensation beyond travel and meeting expense reimbursement.
ISMP staff provided data collected from MERP to develop high-priority topics on I.V. push medication safety. The high-priority topics were grouped into three categories: I.V. push medication preparation, I.V. push medication administration, and best practices.
Summit participants were divided into three groups and addressed each high-priority topic in breakout sessions facilitated by ISMP staff. My group consisted of professionals from anesthesia, nursing medication safety, and the ENA; clinical nursing and pharmacy regulatory compliance supervisors; and more. The facilitators presented statements and questions to the summit participants related to I.V. push safety to generate discussion. We were given three response cards labeled “should,” “shall,” and “must” that we used to answer or reply to the statements presented to us.
- Should indicated a recommendation. This response choice was used to indicate a best practice that's strongly encouraged but may not be applicable to all institutions in all circumstances.
- Shall was used to indicate what's considered a minimum standard or best practice.
- Must was a mandate. This card was used to indicate a requirement established by law, regulatory accrediting bodies, or other authority.
As one would expect, responses were rarely unanimous, but each of us was encouraged to speak to the issue being discussed, bringing our own unique perspectives and rationales to the table. We voted again after the group discussion, and in most circumstances, the majority consensus was accepted. On some issues, such as the practice of further diluting prefilled medication syringes, we had to agree to disagree.
The larger group reconvened at the end of each day for further discussion, focusing on topics in which a consensus was difficult to achieve. A draft version of the summit findings was sent to each participant for review and editing. Once those revisions were completed, they were posted on the website for public comment. The ISMP team then prepared a final consensus statement of safe practices associated with I.V. push medications. For the full report, visit www.ismp.org/Tools/guidelines/IVSummitPush/IVPushMedGuidelines.pdf.
Interestingly, I noticed that participants involved in patient care tended to have similar opinions that differed from participants with an administrative background. Nurses with a background in critical care areas, such as intensive care, ED, and anesthesia, tend to have similar practices regarding medication preparation and administration. In fact, many ED nurses mix, prepare, and administer most of their own medications. On the other hand, pharmacy services prepare medications for inpatient medical-surgical units. Despite disagreements, all were professional and respectful, striving to achieve a consensus.
I was one of only two clinical nurses attending the summit. Within my group, I was often consulted on what actually happens in the clinical area at the bedside because most of my group didn't work in patient-care areas. I was able to provide the emergency nursing perspective on I.V. push medication procedures, which differs from most other nursing units. In the unique, but stressful environment of the ED, nurses must quickly but competently complete tasks to efficiently deliver safe patient-centered care, including medication preparation and administration. “Having enough time” is an infrequent luxury in the ED.
Seeing my name printed in the report as a contributing expert was at first a bit surreal since I never really considered myself an expert. However, it was a reminder that RNs have valuable information to offer. Attending this summit bolstered my confidence and self-awareness. The importance of seeking out professional experiences for growth is now more evident to me.
Reap the rewards of collaboration
Branching out beyond the bedside can seem daunting, especially to pre-Magnet era nurses. I encourage those interested in strengthening their professional development to seek and explore the many opportunities available to nurses. Ask those who've gone before you for advice and align yourself with key mentors who can help guide you along the path you choose. Participation in professional activities, such as mine with ISMP, will help nurses realize that we do have a place at the table and the power to effect positive change at the bedside and beyond.
It was professionally rewarding to participate in a collaborative, interdisciplinary project to improve patient outcomes. It's important for us to realize that bedside nursing and professional development complement one another. It's the best of both worlds when clinical skills and professional development coexist.
ISMP: Dedicated to error prevention
ISMP is the nation's only nonprofit healthcare agency dedicated to preventing medication errors and promoting safe medication use. Certified as a Patient Safety Organization by the Agency for Healthcare Research and Quality, ISMP is dedicated to identifying medication errors and near-misses, understanding system-based causes, and sharing practical recommendations that can help healthcare providers, consumers, and the pharmaceutical industry prevent errors. ISMP also collects and analyzes confidential reports of medication-related hazardous conditions, near-misses, errors, and other adverse drug events submitted through the ISMP National Medication Errors Reporting Program.1 For more information about ISMP, visit www.ismp.org. For more details about I.V. push safety guidelines developed at the ISMP safety summit, see “Evidence-based Safe Practice Guidelines for I.V. Push Medications” in the October issue of Nursing2016.2
Editor's note: Michael R. Cohen, ScD, MS, RPH, President of ISMP, contributes the Medication Errors department for Nursing2017 and is a member of the journal's editorial board.