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Should drug administration involve two nurses?

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31 December, 2012

In our practice comment this week Jennifer Kelly states that hospitalised patients with swallowing difficulties (dysphagia) are three times more likely to suffer medicine administration errors (MAEs) than patients without dysphagia. Of greater concern is that the errors found were not minor.

She suggested that single-handed drug administration means that nurses are often unaware that they have made errors and so they are unable to correct or report them.

Readers' comments (38)

  • yes, I really wish we had the staff to have 2 on each drug-round, this would cut down on errors and give nurses more time to make sure patients took their medication. i find it very stressful having to give out medication with constant interruptions (despite tabards etc), the early morning ivabs and pre-op meds after a night shift. If we only have 2 trained nurses per shift then it would not be possible to have them both doing the drug round but no-one cares, it's too expensive to employ the right amount of nurses.

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  • tinkerbell

    in an ideal world, but realistically ain't never gonna happen.

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  • true tinkerbell. the only time that really happens if you have a student with you but then it takes longer as you got to explain drugs

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  • tinkerbell

    Anonymous | 31-Dec-2012 2:03 pm

    yes and i once made a drug error whilst answering a students question whilst we were doing the drugs together, thankfully she pointed it out to me. Top marks to that student.

    Note to self: Always answer students questions once you have actually dispensed the meds with full concentration, it's so easy to make a drug error.

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  • We stopped having two to check drugs because research showed that it was more dangerous, as often neither took overall responsibility and each thinking the other had got it right. Surely we should we creating the environment for safe practice rather than trying to cover for stressed nurses, who in the right circumstances would not make errors

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  • WOT? -- would that be one that can read and one that can count ? Big Problem!

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  • I also prefer to do a drug round on my own. I concentrate much better. When there's two nurses, that's when mistakes take place. Too much chat etc.

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  • George Barnes

    We always used to have two nurses doing the medication round up until the mid 80's. One was the administration nurse and the other was the second checker and "runner." I do think it was better/safer to have a second nurse (didn't necessarily need to be an RN) but then sometimes "better practice" actually means "cheaper."

    Mind you we also used to have ward "domestics" that far back in time and the wards were definitely cleaner... I am sure that having contract cleaners leads to a better service - in terms of saving money! :-)

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  • I find I concentrate better on my own and am fully in control and responsible for my actions but it would be good to have others to deal with the rest of the work during drug rounds so that you don't have constant interruptions. there is some research on how long it takes to return to concentrated effort after any interruption and this could be significant during activities requiring high concentration, accuracy and safety such as a drug round.

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  • further to the above - interruptions during drug round simply should no be permitted except for emergencies when the trolley, cupboard or whatever can be shut down and left. it is far too dangerous.

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  • In paediatrics we don't have 'rounds' as each nurse is responsible for her own patient's drugs. Single checking of a few simple analgesics is allowed but otherwise all is double checked by RN, or students who have passed their maths test. In my last job everything was double checked and, in my experience so far (3 years qualified), errors are very rare. I know children's nurses have a massively different ratio of nurse to patients, which obviously makes a huge difference, and I feel safe with our regime.

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  • Anonymous | 1-Jan-2013 1:37 pm

    sounds like a good idea. would it work on adult wards then drug rounds could be eliminated altogether? it would rely on adequate trained staffing levels though.


    We prepared our drugs on special trays on a 20 to 25 bedded ward and then the nurse administering them checked them again immediately beforehand. this worked very well and with very few known errors. If there were any doubts or calculation difficulties which occurred more with iv drugs, especially chemotherapy, which is not always presented neatly with the amount prescribed in one ampoule, or if we had to calculate by weight or divided dosages, for example, we could always ask a colleague to check it with us. Some were more competent than others and there were always the few who were rather arrogant and refused to ask for help for themselves and others took delight in making those who did look small, but with most it posed no problem and I would prefer someone attempted to make me look silly (the problem is theirs) than cause harm to a patient or damage my career.

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  • tinkerbell

    Anonymous | 1-Jan-2013 1:37 pm

    sounds like a very safe regime, glad to hear it.

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  • I enjoyed reading all the comments and it is obvious that nurses have many solutions to the problems they face. I am familiar with the drug rounds from my training in England and more recently while working in Ireland. I have to admit that I find this a very inefficient system. I have worked predominantly in the pediatric oncology/hematology setting in Canada. Each nurse is responsible for administrating drugs to her own patients. Narcotics and chemo etc are double checked and usually nurses have to take a chemo certification course before administrating chemo. A chart is delivered to the unit each day with the medication for each patient in a separate drawer and only enough medication for the next 24 hrs. Each dose of tables are in separate bubble packs so if your patient have tapering doses then the packs will contain the appropriate dose for the tapering doses. IV meds are usually pre prepared in syringes unless the med is unstable and cannot be pre prepared. In such cases the nurses draw up the meds. Each nurse has a code she uses to access the drug chart to obtain her patients meds. I believe this is a far safer system however more expensive but it saves time for nurses by employing more pharmacy assistants which I believe ultimately saves money as a RN is paid more. I have not worked in England for many years however I did work in Ireland recently and found the system of drug rounds so time consuming and as I worked as a float nurse I would avoid doing the drug round whenever possible. I could not find the meds in the trolley and found that so much time was wasted looking for meds in the trolley. I observed that in Canada there are more ancillary staff and systems that ensure that nurses get to spend more time at the bedside. When I first started working in Canada I found the system scary but quickly grew to love it. I also found that with this system that meds were administered at the appropriate time which was not always the case when I was working in Ireland because the drug round takes so long. I aplogise to all male nurses as I have called the nurse she in my post (to keep things simple) Happy New Year

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  • George Barnes - I remember always having two doing the drug round in England until the late 80's. After that it got very time consuming doing it alone, with dwindling numbers of nurses, especially enrolled nurses who could look after the ward while you could concentrate on the drug round.

    I now work in Australia and RN's only give drugs to their allocated patients on their shift. Obviously, you get someone else to check certain drugs like IV's, morphine etc, but it does make it easier. On the other hand in nursing homes here, you are usually the only RN on shift for, say 50 residents (as usual, aged care gets short changed in the funding allocations) and spend almost the entire time going from one drug round to another, with constant interruptions. Very stressful.

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  • We did have 2 nurses doing drug rounds at one time, and it didn't show any reduction in drug errors, so stopped. That was when drugs were administered from a medicine trolley. For about the last 15 years patients have had their drugs in medicine cabinets attached to their bedside lockers, which only needs one nurse to administer. Other medications like CDs, IVs etc continue to have 2 nurses to check, and both nurses check patient ID at the bedside.

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  • michael stone

    I can't really comment much about this one, but as an academic problem it has some interest.

    However, I have noticed some comments about systems where nurses only administer drugs to 'their patients' - interesting because you would presumably be more familiar with the clinical situation of 'your patients'.

    Might, on similar logical grounds, a reasonable compromise be 'if a nurse is required to administer a drug he/she isn't very familiar with, a colleague who is familiar with the drug in question should also be involved' ?

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  • Florence

    Ideally two nurses would be on a medicine round. However I do concentrate better on my own.
    Where our Trust falls down is that we dont need two signatures for IV'S and injections. I know that common injectables like Tinzaparin are pre- dosed but Ive nearly made an error by picking up but thankfully not giving the wrong dosed syringe.
    The issue here is Staffing levels and interuptions. Even when I have my HCA in my Bay. I can't expect them to do everything while I administer drugs. I am firm and say no as often as I can but sometimes you have to go and help them.
    A lovely colleague of mine made a drug error recently. It was down to pure anxiety. She had come for the night shift. The 2nd trained agency nurse hadn't turned up. I stayed behind to help give the IV'S and check a controlled drug with her. This was inbetween me trying to locate our Agency Nurse.
    My colleague was so anxious and fed up at the possiblity of another night on her own without trained support she made the error. It was a minor error with oral medication.The Patient was fine and I gave her sensible explanation and apology.
    Our Hospital at Night Practioner reviewed the Patient as did the Doctors.She had bloods, ECG and there were no ill effects.
    Our staffing issues, mainly on the night shifts had been an on-going issue for some months Partly due to sickness but due to staff vacancies too. And also because our ward had been sending one substansive staff member to our Escalation ward. However they would not consistently send us an agency nurse to cover our substansive member we had given them
    Our Hospital at night Practioner brought our staffing issues to the attention of Senior Managment. This hadn't been done by our Ward Manager. He had noted the number of times he attended our ward in recent months to find us short staffed.
    I just felt it was a shame that a Patient may have been harmed by a drug error to bring our Staffing issues to managments attention.
    I always report staffing issues . It's not a blame issue. Its about safety.
    I also felt for my colleague who is very concientious.

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  • staffing levels, anxiety, constant interruptions, not knowing what to do first, prescription errors all lead to drug errors. That is a fact, until these things are addressed and corrected then nurses will continue to make errors. The nurse will of course be the only person blamed - 'you should have told people you were doing a drug-round' - usual old rubbish.

    some nurses rush through the drug-round which they get criticised for, others take a long time which they also get criticised for.

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  • Drug administration is time consuming whichever methods are employed. Whilst the nurse is tied to this duty, the "care" is left to those less experienced or qualified who may miss subtle changes that often occur in deteriorating patients.
    Wouldn't all this be resolved if we let pharmacists do the drug rounds? They are after all the most knowledgable regarding the pharmacology, pharmacodynamics and pharmacokinetics of medicines.

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