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Running head: NURSING INTERVENTION

Therapeutic Nursing Intervention

Diana Pulido
Old Dominion University
School of Nursing

Running head: NURSING INTERVENTION

Therapeutic Nursing Intervention

Patient safety continues to be a topic of concern in all clinical settings, especially for
those placed under pressure such as the hospital. This action required by the 2015 Hospital
National Patient Safety Goals developed by the joint commission (JACHO) with the purpose of
preventing medical errors (2015 Hospital, n.d.). According to the Medical Journal BMJ, it is
"the third leading cause of death in the U.S (Daniel, 2016). This paper focus on the infusion of
the high-alert medication Potassium Chloride (KCL). Castle Medical Center (CMC) located in
Kalua, HI is considered the primary health care hospital for the windward side of the island. This
facility offers inpatient, outpatient, and home healthcare. It is composed of 160 beds, offers
employment to over 1,000 associates and over 300 Physicians (Who We, n.d.). A department is
known as Laulima meaning "many hands working together" is a telemetry unit that consists of
42 beds; 28 semi private and 14 private rooms, it offers day or night 12-hour shift employment.
This unit offers a 4:1 nurse to patient ratio during days and a 5:1 ratio during nights, it is staffing
to include nursing Aides depends on Laulimas current patient census. Citrix is currently the
eChart system this facility uses. The majority of patients seen in this unit are those who require
constant monitoring, including patients with chronic heart failure, arrhythmias, sepsis, postsurgical, renal failure, COPD, advance cancer, ICU downgrades. Its acuity of care places this
department under-pressure as nurses and their aides often describe. One of the daily interventions
perform in Laulima (Telemetry) is the replacement of electrolytes to prevent cardiac arrhythmias,
quite often, physician order these to be replaced via the intravenous route, especially when levels
are critically low. One of the suggestions made by JACHO on high-alert medication
administration was to Double check pump rate, drug, concentration and line attachment,
unfortunately, nurses overpass this suggestion placing their patients at risk of injury.

Running head: NURSING INTERVENTION

Present the Clinical Problem

According to the joint commission, potassium chloride has been identified as one of the
medications "that have the highest risk of causing injury when misused" known as the high-alert
medications ("The Joint", 1999). One of the factors that cause wrong administration is not having
a system that requires two nurses verification. Nurses in Laulima are not verifying potassium
chloride infusion administration with other nurses as the system Citrix does not require a second
nurse verification prior to its start. This situation can become a problem when nurses found
themselves under pressure, perhaps rates can be overlooked which increases chances of harm.
This problem was selected due to a recent sentinel event with no harm performed by a nurse who
was under pressure from her patient, family and providers demands. Physician order D5W with
20mEq of KCL run at 100ml/hr for an NPO patient whose potassium level was 3.0. The
medication was obtained by the nurse, the label high alert medication was scanned as routine, a
litter size dextrose in water with 20mEq of potassium chloride infusion was changed using the
appropriate set up (a volumetric pump and a labeled tubing), guardrails set up was not used, the
infusion was run as regular intravenous fluid. Later on, during hourly rounds, the nurse noted the
infusion rate was different from what it was believed it was started (100ml/hr to 200ml/hr). It is
unknown how this rate change happened but the nurse took full accountability due to the
uncertainty of the started rate.
Current Clinical Practice
One of the standard of practice this facility requires is to scan all medications prior to
administration using the Citrix application, this type of error is not common in this facility
according to risk management. After this incident, the policy of the hospital was reviewed for
compliance with practice. The policy clearly stated potassium chloride is considered a high-alert

Running head: NURSING INTERVENTION

medication, it must be diluted with compatible fluids, infusion should be provided at slow rate, is
never ordered as IV push or IM injection, an IV infusion pump must be use, pharmacy must label
it as high alert, nurses are to label tubing as high alert, medication should be available in mini
bags of 10mEq and 20mEq KCL in 100ml sterile water or in a liter size bags containing 20 mEq
KCL in D5W, NS, D51/2 NS, other greater dosages must be mixed by pharmacy. The infusion
rate should not exceed 20mEq/hour, with an exception of severe hypokalemia with should not
exceed 40mEq/hour. Littler bags and 10 mEq mini bags of KCL can be infused via peripheral
lines, 20mEq of KCL minibags should be infused via central line. Extreme care must be taken to
prevent extravasation, educate the patient to notify the nurse if discomfort occurs. Second nurse
verification is not stated in updated policy (Policy, 2015). Current nursing practice is to place
the infusion under a system within the volumetric pump known as Guardrails. This system
provides the accurate and safe way of administering medications by providing the hospital's
standard of medication administration such as dosing limits, bolus doses, concentration limits,
rate limits, duration limits and clinical advice to deliver medication (Beattie, n.d.). As these two
were analyzed, one discrepancy was found which it was running the infusion at the ordered rate
or as policy requires staff to run infusion at a slow rate. The nurse followed the protocol by
medication verification via scan, usage of a pump and had to tube labeled as high alert. CMC
policy does not require second nurse verification for this high-alert medication.
Nursing Interventions
Weber research article suggests No Interruptions Please as it was identified most
medication errors in critical care settings occur during the prescribing and administering phases
of medication delivery. In a mixed methods study14 of the effect of interruptions on nurses
cognitive work, medication administration took up 17% of the nurses time and each nurse

Running head: NURSING INTERVENTION

averaged 30 interruptions per shift. Performance level failures that accounted for medical errors
in a medical and coronary ICU were due to inattention or failure to carry out intended actions in
patient care(Anthony, 2010).
o

Support intervention EBP. An observation study was conducted to test the

hypothesis that medications errors are increased due to interruption during
administration, and it was concluded that "Among nurses at 2 hospitals, the occurrence,
and frequency of interruptions were significantly associated with the incidence of
procedural failures and clinical errors"(Westbrook, 2010), to identify the reason for this, a
experimental study was performed and suggested interruptions produce negative
impacts on memory by requiring individuals to switch attention from one task to another.
Returning to a disrupted task requires completion of the interrupting task and then
regaining the context of the original task (Westbrook, 2010).

Support intervention Literature. John Hopkins Hospital implemented three

interventions such as using a vest to identify that the RN is administering medicine,
limitation of up to three people in the room, block of call bells and phone call, to identify
if interruption and distraction increase medication administration errors and it was
concluded that "the number of distractions decreased from 98 to 34, which is a 65%
reduction in the number of distractions. Interruptions increased from 14 to 24, which is
a smaller N, but is still a 60% increase. Combining both distractions and interruptions
still showed a significant decrease at 52%." (Alessandro, 2010).
The Institute for Safe Medication Practices suggests to Double Check Judiciously

meaning that independent double checks should only be used for very selective high-risk tasks
or high-alert medications (not all) that most warrant their use. Selected tasks and medications

Running head: NURSING INTERVENTION

should not be based simply on those which have historically always been double checked, but on
a careful assessment of scenarios with the greatest risk (Independent, 2013).
o

Supported Intervention Literature. A systematic review was conducted to

identify the accuracy of current research studies regarding independent double check
practice and found that "Almost all were qualitative studies, reflecting information
gleaned from interviews, surveys, etc. Only 3 studies had quantitative data and showed
relative reductions in the 30% range for medication administration and pharmacy
dispensing errors. The authors conclude that there is insufficient evidence to either
support or refute the practice of double checking the administration of medicines and that
clinical trials are needed to establish whether double checking medicines are effective in
reducing medication errors" (Alsulami, 2012).

Support intervention Literature. Independent double-check (IDC) is a good

strategy to perform to decrease medication administration, nevertheless, there is still the
lack of research that supports this practice. After reviewing the literature, certain
environmental factors were identified that could contribute to medication administration
errors overcrowded medication rooms, interruptions during preparation, and workload
demands (Grant, 2015).
Journalist Maddox, suggested the usage of IV Infusion Safety Technology such as

safeguard system within the pumps, as evidence-based research has reported "Computerized IV
infusion safety systems ("smart pumps") are specifically designed to avert IV infusion
programming errors and provide actionable data on various aspects of the averted errors",
"multidisciplinary team identified implementation of an IV infusion safety system as the best
initial approach to safeguard patients against high-risk medication errors" (Maddox, n.d.).

Running head: NURSING INTERVENTION

Supported intervention Literature. A journal published by Vanderveen

supported the usage of smart pumps with the integration of a closed-loop medication
administration safety system automatically sending infusion orders directly to each
smart pump and infusion data back to the EMR helps ensure correct infusion
programming and timely, accurate capture of infusion data, which the nurse can then
approve and enter (Vanderveen, 2013).

Supported Intervention EBP. A controlled trial was performed with the goal of
identifying if smart infusion pumps would improve medication safety and it was
concluded that " Intravenous medication errors and adverse drug events were frequent
and could be detected using smart pumps. We found no measurable impact on the serious
medication error rate, likely in part due to poor compliance. Although smart pumps have
great promise, technological and nursing behavioral factors must be addressed if these
pumps are to achieve their potential for improving medication safety (Rothschild, 2005).

By analyzing the problem, it was concluded that the environment was a contributing factor to
this error, however, it was hypothesized that if the above interventions (safeguard usage, IDC for
Potassium Chloride infusion and distraction reduction) were transferred into practice, this type of
medical error can be avoided. A way to implement these can be done via addition to current the
policy once is added, it is important to increase awareness which can be achieved by having a
mandatory in-service for both shifts.

References
2015 Hospital National Patient Safety Goals. (n.d.). In The Joint Commission. Retrieved from
http://www.jointcommission.org/assets/1/6/2015_HAP_NPSG_ER.pdf

Running head: NURSING INTERVENTION

Alessandro, M. (2010). Medication Interruptions and Distractions. In Maryland Patient Safety

Center. Retrieved from
http://www.marylandpatientsafety.org/html/education/solutions/2010/documents/commun
ication/Medication_Interruptions_and_Distractions.pdf
Alsulami, Z. (2012, March 14). Double checking the administration of medicines: what is the
evidence? A systematic review. InArchives of Disease in Childhood. Retrieved from
http://adc.bmj.com/content/97/9/833.abstract
Anderson, P. (2015). Preventing High-alert Medication Errors in Hospital Patients. In Medscape
Nurses. Retrieved from http://www.medscape.com/viewarticle/846296_7
Anthony, K. (2010, June). No Interruptions Please Impact of a No Interruption Zone on
Medication Safety in Intensive Care Units. In American Association of Critical Care
Nurses. Retrieved from http://ccn.aacnjournals.org/content/30/3/21.full.pdf+html?
sid=f5725153-529b-4522-a5f9-ee75cea4e64c
Beattie, S. (n.d.). Technology Today: Smart IV Pumps. In Modern Medicine Network. Retrieved
from http://www.modernmedicine.com/modern-medicine/content/technology-todaysmart-iv-pumps?page=full
Daniel, M. (2016, May 3). Medical error the third leading cause of death in the US. In them.
Retrieved from http://www.bmj.com/content/353/bmj.i2139
Grant, D. (2015). Navigating Independent Double Checks for Safer Care: A Nursing Perspective.
In the University of New Hampshire. Retrieved from
http://scholars.unh.edu/cgi/viewcontent.cgi?article=1244&context=honors
Independent Double Checks: Undervalued And Misused: Selective Use Of This Strategy Can
Play An Important Role In Medication Safety (2013, June 13). In Institute for Safe

Running head: NURSING INTERVENTION

Medication Practices. Retrieved from

http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=51
Maddox, R. (n.d.). Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best
Practices, and Smart Technology Help Avert High-Risk Adverse Drug Events and
Improve Patient Outcomes . In Agency for Healthcare Research and Quality. Retrieved
from http://www.ahrq.gov/downloads/pub/advances2/vol4/Advances-Maddox_38.pdf
POLICY & PROCEDURE: POTASSIUM CHLORIDE INFUSION. (2015, December 4).
In Castle Medical Center Adventist Health.
Rotschild, J. (2005, March). A controlled trial of smart infusion pumps to improve medication
safety in critically ill patients*. InCritical Care Medicine. Retrieved from
http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?
year=2005&issue=03000&article=00010&type=abstrac
Vanderveen, T. (2013, April). Intravenous Infusion Safety Initiative: Collaboration, EvidenceBased Best Practices, and Smart Technology Help Avert High-Risk Adverse Drug
Events and Improve Patient Outcomes . In Patient Safety and Quality Healthcare.
Retrieved from http://psqh.com/intravenous-infusion-medication-safety-the-visionbecomes-reality
Westbrook, J. (2010). Association of interruptions with an increased risk and severity of
medication administration errors. InJAMA Internal Medicine. Retrieved from
http://archinte.jamanetwork.com/article.aspx?articleid=415843
Who We Are. (n.d.). In Castle Medical Center Adventist Health. Retrieved from
https://www.adventisthealth.org/castle/pages/about-us.aspx

Running head: NURSING INTERVENTION

10

Honor Code:
This statement will be included on all work handed in for credit and signed. The Honor Pledge
states:
"I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community it is the responsibility to turn in all suspected violators of
the Honor Code. I will report to a hearing if summoned."

Name: Diana Pulido

Signature: DianaCPulido
Date: June 13, 2016