Shortcuts in Medication Administration: Why Do We Do It Wrong If We Know How to Do It Right? (and We Do!)

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challenger-by-andrew-coulter-enright-flikrMany of us associate faulty O’rings with the catastrophic explosion of Challenger in 1986 and a problem with the heat and tiles that caused the burning up of it’s sister ship, Columbia, during reentry in 2003.  But, these defective materials/production issues were more like symptoms of a much deeper and insidious problem known as the Normalization of Deviance.  Basically it refers to doing something the wrong way many times without any bad consequences.  A bad habit evolves.  But the right way of doing certain things is the right way for a reason and eventually these bad habits lead can lead to catastrophe.

For instance, take a look at the administration of medication in nursing process. As you can see, (and if you ARE a nurse, already know) it involves a very specific process of matching doctors orders to dispensed medication and identifying the right dose, person, time, route, (by mouth, topically, subcutaneous or intramuscular injection, etc). These steps are drilled into us in nursing school and clinical rotations.  WE KNOW how to do it right.

BUT try to enact this process during an understaffed shift or in the midst of endless interruptions and it can be humanly impossible to do it right all the time!  Shopillsrtcuts like these that may be survival mechanisms during such a shift may begin to take root in every day medication administration, especially if understaffing or endless interruptions are chronic:

Shortcuts like these that may be survival mechanisms for understaffing, fatigue, excessive stress... Click To Tweet
  • Relying on memory from earlier in the day or previous shift for some steps.
  • Stopping in the middle of the process to answer an alarm and then rather than restarting the process picking up where ‘we’ think we left off.
  • Trusting the pharmacy sent the right dose/medication.
  • Gauging timing as close enough and may be the only opportunity.
  • Patient is sleeping and don’t want to wake and there is dried up speghetti sauce on the bracelet bar code, (or scanner isn’t working or someone else has it).

(“Jaws” theme music would be appropriate here!)

Mostly these shortcuts don’t lead to errors or I should say problems, because the shortcuts ARE errors!  But then some day a catastrophe happens, patients and families are hurt, nurse and physician’ careers are ruined, and we look back and say, “How could this have happened?”

Not only are bad habits bad b/c they're unsafe, they are secrets, withheld by shame, fear, & inadequacy. Click To Tweet

I don’t believe we really even know how often these shortcuts are made because they are taboo to talk about.  Loss of license and/or respect are likely worries.  Not only are the bad habits bad because they are unsafe, but they are also secrets, withheld by shame, inadequacy and fear.

So how do we prevent nurses from developing these bad habits?

WE DO THE THINGS THAT SUPPORT THE RIGHT WAY!  These are important keys to administering medications and following any procedure safely.  If you are a healthcare professional or consumer, what else would you add to this list?

  • Training and review in the processbb headshot 2nd city T 10-13 Cherations
  • Realistic workloads
  • Quiet zones
  • Enough administrative staff available to answer general questions/interruptions
  • Enough nurses to handle appropriate interruptions/questions
  • Ensure med cart supplies are well stocked
  • Communication training in assertiveness & opportunities to practice with feedback and learning curve
  • Medical improv training  (A unit who co-creates their own solution will inherently be invested in it!)

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25 Responses to Shortcuts in Medication Administration: Why Do We Do It Wrong If We Know How to Do It Right? (and We Do!)

  1. Kelly Payne says:

    The biggest problem I currently see is that we have an overabundance of IT issues without a good tracking system. One nurse will put in a work order for a medication scanner and then days later someone will appear asking for that nurse (but of course she isn’t still here?) then they leave the problem unresolved… When we do not have the proper equipment to follow through with set policies and procedures on medication administration we have to rely on shortcuts. It is bad habits & they need to be addressed…

    • Beth_Boynton_RN_MS says:

      Great point, Kelly. I see it as a communication failure! Your example is a perfect one that shows how a easily a problem gets lost even though a nurses attempted to report an issue. I wonder, why isn’t that report picked up right away and would advise any policy makers to make sure the nurse who reported the issue gets some feedback about what was done to solve the problem. This helps the reporter to realize her or his efforts were taken seriously and encourages future reporting. (It is listening in a way!)

  2. Elizabeth Scala says:

    I love your solutions, Beth. I believe that when we focus on what we want to achieve, as you did with your suggested answers to these challenging issues, we can get there. It takes one person, one action at a time! Thanks for sharing.

  3. Gregmercer601 says:

    Sound advice, but unless we also attack the systems issues, the understaffing, the puting of profits above safety, then nurses will continue to do their best in difficult and at times impossible circumstances, mistakes will results as is inevitable under such conditions, and they will be made scapegoats by those who would preserve the circumstances that create the errors.

  4. Great article. Shortcuts don’t work. You can always get another job, not another license.

    • Beth_Boynton_RN_MS says:

      Thanks, Lorie and powerful point! I understand nurses in the short term who may be reluctant to leave or even afraid, but in the long run practicing safely and according to standards of care will ensure longterm rewarding careers in the long run.

  5. allewellyn says:

    Good information and reminders for seasoned nurses. So often we think taking shortcuts gives us more time, but in reality can cause problems. I think quite zones are so important and something we did not have when I was in active practice.

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  17. Great article on the habituation of negative routines Beth.

    I’d like to add one intervention to the list, a method that takes us out of our habituated way of doing things, e.g., Normalization of Deviance, and brings us into what we’re doing in the present.

    I can think of no better way to teach nurses moment-to-moment awareness, or “situational awareness,” as the phrase has been coined, than through teaching mindfulness and meditative awareness to nurses and to nursing students before they even enter the profession.

    Meditation is a state free from distraction, where one’s mind isn’t altered or stirred up by other thoughts, situational circumstances, or other forms of distraction.

    Imagine a nursing profession where working (and living!) in moment-to-moment awareness was the norm. Imagine being able to be in the understaffed and overworked environment of the modern hospital setting, while still keeping one’s mind in a state of relative ease and equipoise.

    Let’s get mindfulness into the curriculum of every nursing school and hospital-based continuing education program. Let’s become a profession of mindfully aware and compassionate caregivers. And then…let’s create a more mindful, aware, and compassionate workplace!

    • Hi Jerome,
      Thanks for your feedback and input re: mindfulness. Creating a more mindful, aware, and compassionate workplace is a great goal. I may need some help practicing mindfulness where I work as a per diem RN on a dementia unit. Sometimes I start out a shift with good intentions and give it up b/c of relentless interruptions. I think some of it may be hypervigilance on my part and yet I can’t help but wonder how chronic understaffing may limit my ability to take a deep breath. Perhaps this is a chicken/egg question and trying is enough while meanwhile trying to advocate for more staff. Your thoughts?


  18. Stacy Goff says:

    Hi Beth,

    I enjoyed reading your post. I am an ADON at a long-term care facility. I started out as a CNA, obtained my LPN license, then went back to school to get my RN degree. As a floor nurse, and now an administrative nurse, I can definitely agree on the challenges involved in completing a med pass on 25+ patients in a 2 hour period with all the varied interruptions. I think we all agree that the expectations are unrealistic. The obvious solution is to decrease the patient to nurse ratio but that doesn’t seem to be an option Medicare/Medicaid is willing to embrace. I deal with frustrated nurses daily who cannot complete their med passes plus the required ducmentation within an 8 hour shift. It hurts to see dedicated nurses struggling with the need to provide compassionate patient care while feeling pressured to complete required paperwork and still clock-out on time. I don’t know what the solution is within the constraints of the present economy but I believe that our industry’s expectations need to be more realistic. “Do more with less” has become the mantra. That may work for a short period of time, but in the long run, the patients are the ones who suffer.

    • Thank you for your heartfelt comment, Stacy. You know, I suspect that optimal collaboration and delegation skills would help to solve this dilemma a little but at some point we have to address the unrealistic aspect. We are human and cannot function on overdrive all the time. We can’t. So do we “sell” a different package? Encourage or maybe insist that families participate more or accept a lower standard? Maybe so. I work per diem in LTC and frankly want to scream at times because of this gap in what we are expected to do and what we can do. I sometimes wonder if a group of frontline staff, an ADON, and medical director could get together and make some changes. Like ordering meds AM and PM, more prns and less scheduled tylenol, laxatives, stuff that could be addressed only when needed. Docs need to get some empathy for nurses in this role and may have some other ideas to eliminate extra work. 25 patients in 8 hours, or 7.25 hours if nurses take meal and rest breaks comes out to a little over 17 minutes per patient per shift. Add a dressing or one patient who is really sick or combative and well you know the story. Maybe if patients and families got a brochure that said, “Welcome to Pine Haven. We’ll do our best and want you to know that your loved one has a nurse available to give meds and other treatments for about 20 minutes a shift or 1 hour per day!” (Rather than, Welcome to Pine Haven. Our staff is dedicated to providing compassionate care to your loved one 24/7 blah blah blah) Maybe this is another kind of transparency we need in healthcare to eventually get consumer clout for change. Take care and I so appreciate your concern for both patients and staff. Beth

  19. Mary A. Cassese says:

    I am a nursing professor and I am very familiar with how meds are “passed” at the present time. Being a nurse for 40+ years, I feel compelled to share how medications were handled way back when. We had a “med room” where we would go to prepare our medications. When a nurse was in the med room, nobody interrupted the process, not a phone call, not a patient light not another nurse with a question that could wait, nothing except a life/or death emergency. In 40+ years of nursing, I NEVER made a med error because, as you mentioned, I followed the basic rules and was never distracted (that was pre 1990). Even our nurse colleagues would “protect” the solitude of the nurse who was preparing meds. It was sacred ground. Now fast forward to 2013… nurses go from room to room with their med carts/computers and most of the preparation occurs in the hallway. Anyone and everyone interrupts the nurse plus there are so many additional distractions, dietary, physical therapy, visitors, students and the list goes on. In the present environment, it seems that the best option is to bring the computer to the bedside and close the door/curtain but even this is not optimal because there are still interruptions. The current system gives us much to think about. Assertiveness, communication may be key. Maybe a “new” system of team nursing, perhaps an RN team leader to oversee patient care with a med/treatment nurse to do assessments and nursing assistants working as part of the team. But that would mean hiring more direct providers, oh my! Where would the money come from?…maybe we could begin to look at the inflated salaries of the folks who “run” the hospital, oh yes those over paid people in the “C” suites across the country! OMG, did I just actually say that out loud!!!

    • Hi Mary,
      Thanks so much for your comments and experiences about how medications used to be passed administered. It sounds like there was a respect for the process that has been eroded. I remember a med room too, I think it was for narcotics only.

      I think you are right on that assertiveness is key!

      “I need help!”
      “I am too tired to work safely.”
      “Doctor, that’s the wrong leg!”

      You might enjoy this 12 min youtube!

      Interruption Awareness: A nursing Minute for Patient Safety

      I DO like your new system….more people to do the work…maybe throw in some delegation training for nurses, (another way to develop assertiveness), and re-evaluate leadership salaries. I’m glad you said it out loud!

What are your thoughts?