Correctional Nursing Peer Review (podcast)

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cnt-podcast_cover_art-1400x1400Peer Review for Nurses? Many correctional health care settings are gearing up for correctional nursing peer review as NCCHC implements new accreditation standards this month. In this episode correctional nurse experts Catherine Knox, Kathy Page, Becky Pinney, and Pat Voermans join Lorry to discuss correctional nursing peer review and changes in the NCCHC accreditation standards for standard C-02 – Performance Enhancement.

The performance enhancement standard has been around for many years and focused on peer review for medical providers. This latest revision now includes all licensed staff; thus adding RN and LPN team members to the peer review process.

Panelists discuss the importance of this change for correctional nurses and nurse leaders. They also dispel some common misconceptions about nursing peer review; differentiating peer review from annual performance review and competency evaluation. Practical ways to perform nursing peer review are also described.

A series of blog posts about correctional nursing peer review can be found on the Essentials of Correctional Nursing blog.

In The Nursing News

How is Ebola Transmitted?

Lots in the news about the Ebola virus hitting US soil. Since much is still unknown about the virus and no vaccine or medication treatment is yet available, it is important to be careful around anyone who may be infected. Nurses, in particular, spend time in close contact with patients so we need to know about transmission and protection. On October 15 the CDC increased their caregiver protection barriers to more closely match World Health Organization recommendations. Standard precautions for droplet and body fluid contamination were enhanced with double gloving and full body coverage, including head and neck. Important points:

  1. Ebola has been detected in blood and many body fluids. Body fluids include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen.
  2. The virus is spread by direct contact; meaning that body fluids (blood, saliva, mucus, vomit, urine, or feces) from an infected person (alive or dead) have touched someone’s eyes, nose, or mouth or an open cut, wound, or abrasion.
  3. Ebola is killed with hospital-grade disinfectants (such as household bleach). Ebola on dried on surfaces such as doorknobs and countertops can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.
  4. Although coughing and sneezing are not common symptoms of Ebola, if a symptomatic patient with Ebola coughs or sneezes on someone, and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease.

Would your health care unit have the equipment necessary to protect you should you need to isolate a patient for evaluation for Ebola infection? Think about this now and have the conversation. Be prepared.

Men with Osteoporosis are Neglected

The International Osteoporosis Foundation has published a report on osteoporosis in men. Although we tend to think about osteoporosis as an elderly female condition, a third of all hip fractures occur in men. Men are prone to brittle bones as they age; particularly after the age of 70 when testosterone reduces significantly. Other factors contributing to osteoporosis in men include smoking, drinking more than 2 drinks per day, low vitamin D levels, a family history and taking certain medication such as cortisone, antiepileptic drugs and SSRI antidepressives. If you care for elderly male inmates, consider osteoporosis and concern for falls.

USPSTF: Screen Everyone 45 and Older for Abnormal Glucose

The US Preventive Services Task Force drafted new diabetes screening guidelines recommending that everyone 45 years and older should be screened for abnormal blood glucose and type 2 diabetes. They hope to identify those with abnormal glucose levels to initiate lifestyle interventions before the condition progresses to diabetes. The guidelines are open for comment until early November, 2014.

Patients Listen More to Female Doctors

An interesting French study suggests that patients heed guidance more regularly from female providers than from male. The study design hypothesized that patients would listen more to a physician of the same gender but it turns out that both male and female patients were more disposed to listen to a female physician. Based on this and prior research the authors suggest that female doctors may be more collaborative with patients and male doctors more dominant. Also, earlier studies have shown that women doctors report feeling more comfortable discussing personal and sensitive issues. It would be interesting to see a similar study regarding nurse-patient relationships.

Making Ends Meet: The Blunt End and Sharp End of Clinical Error

A 33 year old male inmate from a maximum security state prison was admitted to a community hospital with flank pain and hematuria. His Arrow Chamber Funnel ChartINR was discovered to be 8.2 (therapeutic range 2-3). His medical history included deep vein thrombus resulting from Protein S deficiency. A medication error investigation revealed that the patient had been receiving three times the amount of the current order of warfarin (Coumadin) and no INR diagnostic tests had been completed for the last 2 weeks.

Investigating What Went Wrong

Hundreds of doses of medication are administered every day in most correctional facilities so it is not surprising that medication errors are some of the most common to emerge in practice. Investigating errors can lead to information necessary to make improvements to reduce future risk. An error can result from poor decisions and actions along the entire medication use system: ordering, transcribing, dispensing, administering and monitoring. Often poor practices are found in several areas that result in an incident.

Blunt End/Sharp End Evaluation of Clinical Errors

A helpful model of error causation looks at the various components of a clinical error as an inverted triangle with the point of care being at the sharp end and the various complexities of organizational structure, system, and process being at the blunt end; removed from the actual error episode. Blunt end components, then, contribute to an environment that either encourages or does not prevent the error under consideration.

Case Analysis by Blunt End/Sharp End

Figure 1.2The Blunt End/Sharp End model provides a framework for evaluating a clinical error like the one described above.

Sharp End: Investigating the sharp end of the error focuses on the actions of the clinicians in direct contact with the patient. Here are some sharp end investigation questions for this case:

  • Did the nurse follow standard medication administration safety steps when administering the recent doses of warfarin?
  • Were there multiple strengths of the medication in the medication cart and did the nurse administer an incorrect dose?
  • Did the prescribing provider order the strength of the doses administered?
  • Did the prescribing provider order INR lab tests?
  • Were the tests completed but not reviewed or documented in the medical record?

Blunt End: Investigating the blunt end of the error focuses on the policies, procedures, systems, resources, and constraints surrounding the incident. Here are some blunt end investigation questions for this case:

  • What are the policies regarding INR evaluation while on warfarin?
  • What tracking systems are in place for patients on anticoagulation medication?
  • Is there an adequate process for discontinuing previous medication dosing when new dosing is ordered?
  • Are nurses working in this area appropriately oriented to the medication administration process?
  • What percentage of the nursing staff are new, float, or agency staff?
  • How much overtime or double shifts are nurses in this unit working?
  • What communication system is in place for nurses to question medication orders?

Always Look Upstream

When investigating significant errors such as the one above, it is easy to fall into several mental biases.

Attribution error bias: It is easy to pin an error on a character flaw or defect of the clinician at the sharp end of the error. Rather than look for all issues, evaluators stop at the shortcomings of staff members involved in the incident.

Confirmation bias: Making a quick judgment of the cause of an error can lead to accepting evidence that supports that judgment while neglecting evidence that would favor other causes. If an organization is prone to evaluating only the sharp end of a clinical event, evidence supporting this view would encourage investigators to stop looking elsewhere.

Hindsight bias: Actions and outcomes viewed after the fact show an ‘obvious’ path of cause and effect. At the time of the actual event, however, multiple possibilities vie for attention, making the future less apparent. Investigators must consider the event from a perspective of an unsure outcome.

By intentionally looking upstream to the blunt end of a clinical situation, the full picture is able to be evaluated and meaningful process and system corrections can be made; leading to reduced risk of future error.

In the case presented above, faulty medication discontinuation practices, poor interdisciplinary communication (both written and verbal), along with inconsistent medication validation at the point of administration contributed to the poor patient outcome.

How do you evaluate clinical error in your setting? Share your process in the comments section of this post.

Information from this post comes from Chapter 1 of my new book: Correctional Health Care Patient Safety Handbook: Reduce Clinical Error, Manage Risk, and Improve Quality (affiliate link). Click on the link to purchase a print or ebook version. Or, enter my raffle for your own free copy – 3 winners. Hurry, raffle ends November 1: Raffle for a Free Copy of the Patient Safety Handbook

Photo Credit: © John Takai – Fotolia.com

September 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurses Margaret Collatt, Jeannie Chesney, and Susan Laffan, join Lorry to discuss the latest correctional health care news in this podcast.

Briefing Paper: The Dangerous Use of Solitary Confinement in the US

The ACLU recently published a briefing paper on the dangers of solitary confinement in US prisons. This has been a topic of interest for some time in corrections news as more and more evidence of the effects of long term confinement emerge. This paper reports that more than 80,000 prisoners are likely held in some form of solitary confinement, be it administrative segregation, disciplinary segregation or protective custody. Panelists discuss the variable nature of what constitutes solitary confinement and the effects as reported in the paper. Sadly, many in solitary confinement are juveniles or have severe mental illness or cognitive disabilities that led to not understanding or following prison rules. The effects of confinement can’t be helping them. What can correctional nurses do about solitary confinement practices is also discussed.

Excited Delirium and the Dual Response: Preventing In-Custody Deaths

Excited delirium is the topic discussed in a recent issue of the FBI Law Enforcement Bulletin. This poorly understood medical emergency is seen fairly frequently in the criminal justice system, particularly involving young males who have drug intoxication or mental illness. If not recognized and treated, respiratory arrest can result in death; often during a take-down situation. I’ve been involved in reviewing several correctional legal cases that involved possible excited delirium and know it can be hard to diagnose, even after the fact. It must be very difficult to recognize and manage in the midst of trying to manage a young, strong, agitated and hallucinating male. Panelists describe their experiences with this condition.

Clinic geared toward health needs of ex-offenders opens in Philly

Philadelphia has opened a city health clinic geared toward ex-offenders and people leaving jail or prison. It is a response to the need for health care for our patient population once released. Most of us know that incarceration is often the first health care experience for many of our patients and chronic diseases end up being identified and treated. Then, once released to the community, follow-up is difficult. Panelists agree that this is a good idea that will hopefully be replicated elsewhere.

Oregon prison tackles solitary confinement with Blue Room experiment

Oregon Live is reporting on the use of nature imagery as a therapy to reduce the mental health effects of solitary confinement at the Snake River Correctional Institute in Oregon. A forest ecologist from the University of Utah, Nalina Nadkarni, suggested the use of images of nature such as beaches, rain forests, and waterfalls could help reorient prisoners in isolation and decrease the mental illness, self-harm, and escalating agitation that emerges with continued isolation.

The therapy was picked up by administration at Snake River in early 2013. They used one of their recreation rooms to play nature videos and were able to convert the room for about $1500. They are seeing some positive results including some reductions in disciplinary infractions. The University of Utah hopes to research the effects of the intervention later this fall.

 

Correctional Nurse Guide to the Code of Ethics: The Nature of Health Problems

North East South West Signpost Showing Travel Or DirectionThis post is part of a continuing series applying the Code of Ethics for Nurses to correctional nursing practice. Find other posts in the series here.

Kim was not happy with her assignment in the large city jail infirmary where she worked. The patient load was manageable but she didn’t want to deal with the patient in cell B-5. Kim was a new mother with an eight month old baby girl. She had done everything right during her pregnancy; strictly following medical advice and not drinking at all. Her baby was born with a slight esophageal defect that required surgery in the early days. Although her baby was doing well, it was a continual concern for her. Now she is struggling with bad feelings toward the pregnant woman in cell B-5 who is six months pregnant and going through alcohol withdrawal while being maintained on methadone for her heroin addiction. How could this woman have so little regard for her child’s future? Kim did not know how she would be able to make it through the shift.

Code of Ethics Proposition 1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

Kim definitely has an ethical dilemma. She cannot get past the nature of her patient’s health problem. She is unable to provide nursing care in this situation with compassion and respect for the inherent dignity, worth, and uniqueness of this patient. What are her options?

Gift Exchange

An easy option would be for Kim to broker an assignment exchange. Another nurse who is less sensitive to these concerns may be willing to care for this patient and get beyond the ethical matter. This exchange provides Kim with the gift of time to work through her ethical dilemma. Smaller facilities may not have enough staff on shift to provide this option or nursing leadership may be unwilling to juggle assignments. Best for Kim to approach a fellow staff member with the idea and then present a plan to the nurse manager for consideration. This can only be a short-term solution, though.

Shifting Perspective

Kim needs to both objectively and subjectively analyze her feelings toward this patient. It may, in fact, be true that this woman is totally disregarding the health of her unborn baby, however, providing appropriate infirmary care is reversing this disregard. Managing the withdrawal of alcohol in this situation may be of great benefit to the baby, as well as the mother. This shift in perspective may allow Kim to engage in an appropriate therapeutic nurse-patient relationship. Caring concern might be what this patient needs to make a life change. Even if this doesn’t happen, Kim’s nursing care will be of benefit to the unborn child.

Out of Body Experience

Kim does not respect or value the actions of this patient. This is true for many of our incarcerated patients. They have made poor life decisions that most nurses would disagree with. Kim is able to overlook this when dealing with other patients. Why is this one a problem? This is the heart of the ethical issue that Kim must struggle through. This patient’s decisions hit close to home as Kim has a young child and is sensitive to how the life choices of this patient are affecting her unborn child. Kim may benefit from considering the situation from a third-party perspective. This practice (sometimes called bracketing) involves consciously setting aside personal feelings or biases in a situation. No doubt, if she has strong feelings about this patient’s seeming disregard for her baby, bracketing will be challenging.

Most important is that Kim actively engage in working through her ethical dilemma rather than respond poorly to this patient or deny that she is having difficulty.

Have you struggled with a similar situation in providing correctional nursing care? Share your thoughts in the comment section of this post.

Photo Credit: © Stuart Miles – Fotolia.com

Wake Up and Smell the Contraband! (podcast)

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cnt-podcast_cover_art-1400x1400Joe Bouchard, corrections author and educator, is a librarian for the Michigan Department of Corrections.  He joins Lorry to talk about contraband and what nursing staff, particularly new staff, need to know.  Joe is well known in the corrections community as an expert on this topic. His book Wake Up and Smell the Contraband! is a popular training guide for correctional professionals.

Contraband can come in many forms:

  • Anything that is prohibited as a possession such as a cell phone.
  • Authorized property that is excessive such as 50 rolls of toilet paper acquired for barter.
  • Something that is acceptable but the possession of another such as another inmate’s CD player.
  • Anything altered for another unsafe use such as a shank created from plastic cutlery.

Items can become contraband in a prison if altered for inappropriate use. For examples, inmates may ask for extra Band-Aids from multiple health care staff members. Once there is a stockpile, the Band-Aids are used to tape a shank under a table.

Hidden meanings and hidden symbols can also be considered contraband from a security perspective. A sleeve cut from a shirt or the way shoes are tied can be communication among prison gang members.

The most dangerous contraband these days is the cell phone. This allows communication outside the walls. They are versatile and can record activities for blackmail.

Common mistakes to avoid:

  • Not following contraband policy and procedure and giving away too much without checking the policy.
  • Not understanding the need for mouth checks. Drugs are a valuable commodity on the prison underground.
  • Not keeping alert to contraband undertakings.
  • Not speaking up when staff are seen in contraband activities. Serious offenses should be reported to a supervisor. Minor offenses that may be due to lack of awareness should be addressed directly with the staff member.

Additional resource:

Misused medications in a prison

Struggling to Define Caring in Correctional Nursing

rock climbingCorrectional nurses face a daily struggle to care for their patients while delivering much-needed healthcare in a restricted environment where they may also fear for their own personal safety. How can nurses truly care for and care about their inmate patient population? This is a question many of us in the specialty grapple with as we try to elevate the professional status of correctional nursing. Caring has been described as the essence of professional nursing practice, therefore we must establish the characteristics of this concept as it is enacted in the criminal justice system.

Weiskopf studied nurses’ experience of caring for inmate patients and discovered a number of limitations in our setting .  Nurses in this study described the need to negotiate boundaries between the culture of caring and the culture of custody to establish relationship with custody staff in order to be effective. One surprising finding of the study was the extent to which the negative attitudes and behaviors of other nursing staff affected nurses who were attempting to provide compassionate nursing care.

Many nurses working behind bars feel an obligation to care and often struggle to find ways to do this in a hostile environment. Yet, developing a structure and process for caring may be the core defining characteristic of our specialty. Here are some suggested ways nurses enact caring behaviors in corrections:

  • Educating patients about their health conditions and self-care principles
  • Maintaining a nurse-patient relationship that is within the helpful zone of professional boundaries
  • Advocating for the health care needs of a patient when necessary
  • Showing compassion and respect
  • Presenting a non-judgmental manner
  • Listening to what the patient is saying
  • Helping patients through a difficult situation

Correctional nurses are confronted daily with a struggle against a tidal wave of organizational culture convinced that we should not be caring ‘too much’ for our patients. Caring for murderers, rapists, and criminals takes true grit and a more serious definition than a superficial application of a warm positive emotional response or empathetic word. We are the ‘Tough Love’ folks on the nursing caring continuum.

Consider these unusual ways that a correctional nurses cares for patients:

  • Not accepting a gift from a patient
  • Letting a patient know that you know the rules and they should not ask you to violate them
  • Asking the patient to complete a sick call request for their rash that they want treated during pill line
  • Being diligent with mouth checks during pill line

All of the examples above constitute an action or activity that is helpful for the patient; whether it avoids penalties, provides boundaries, or prevents self-harm. Caring seeks the best for the other in any situation.

Have you found it difficult to care for patients in the criminal justice system? Share your thoughts in the comments section of this post.

Photo Credit: © Alexander Zhiltsov – Fotolia.com

The foundation of this post originally appeared in the Essentials of Correctional Nursing blog

Patient Identification: Is the Right Patient Getting That Medication?

gloved hand holding plastic cup with pillsRecently I reviewed the medication administration practices at a small city jail. The nurse had been there many years and was able to complete the delivery of medication on 3 floors of inmate cells very quickly. In the unit common area she called out the names of the inmates. Inmates would present themselves and a soufflé cup of pills was poured into their open hand.  This was happening so quickly that I could not always see whether the inmate was tossing the medication into his mouth or his pocket. Neither nurse nor officer did an oral check. No inmate had a wrist band or other identification.

Can you name all the safety issues of concern in the described process? I hope that patient identification was high on your list of concerns along with medication diversion and hoarding risk…..but I’ll leave those last two for another discussion. “Wrong Patient” medication and treatment errors are frequent in health care delivery. They are a top concern for The Joint Commission (TJC) and are high on their list of National Patient Safety Goals again this year.

Times of particular concern for “Wrong Patient” errors are during medication administration, blood draws, blood transfusions, and surgical procedures. For the correctional setting, medication administration and blood draws would be most common.

Improve patient safety by applying these TJC recommendations:

  • Two methods of identification: Two forms of patient identification in corrections may include verbal name check (first and last) and inmate ID#. Photo ID cards or wristbands are ideal. Some computerized systems are able to access digital photos.
  • Involve the patient: Patients should know their meds and ordered lab tests. If there is a question about a medication or test, double-check the order. Patients can often help avoid an error.
  • Label in front of the patient: Label lab tubes in the presence of the patient. This can help avoid tube mix-up.
  • Include patient identification in orientation and training: Don’t leave patient identification processes to chance. Be sure all staff follow safety processes by learning them at orientation and through reinforcement during management rounds.

I shared my concerns with health care administration that day at the city jail described above and made recommendations for how they could improve their medication administration process to include 2 forms of patient identification.

What is your process for patient identification in medication administration at your facility? Share your procedure in the comments section of this post.

Photo Credit: © vvoe – Fotolia.com

This post originally appeared in the Essentials of Correctional Nursing blog.

Scope and Standards: Five Correctional Nurse Roles

ANA StandardsThis post is part of an ongoing series discussing key components of the Correctional Nursing Scope and Standard of Practice, 2nd Ed. Review prior posts in this series here. Purchase your own copy of this highly recommended book through Amazon.*

I love helping nurses discover the invisible specialty that is correctional nursing. In fact, that was my original purpose in starting this blog over 5 years ago. I was sure that if more nurses knew about our specialty then more would join our ranks. From my own experience I know that few nurses get exposure to incarcerated patients during their education. There are practical reason why student nurses don’t have clinical rotations in the local jail, but it hampers the ability for new nurses to consider entering our challenging specialty. Regularly I am asked by new nurses if they should apply for a correctional nursing position. Although I enthusiastically encourage these individuals; I also caution them to be careful in selecting their first correctional nursing position if they are a new graduate. Here is why: Correctional nurses have so many roles and must often do them with little support and resources. This can be overwhelming for a new nurse; who may need a good bit more structure to get a solid foundation for their nursing career.

Based on the Correctional Nursing Scope and Standards of Practice, here are the five leading roles of a correctional nurse.

Primary Care

Correctional nurses are most often the first point of contact for incarcerated patients with healthcare needs. They manage access to all other aspects of healthcare and make determinations of appropriate level and type of care needed. In this way they coordinate ambulatory care provision to the patient population.

Emergency Care

Correctional nurses also provide immediate treatment of injury and acute illness while determining if a life-threatening injury exists that would warrant emergency transport to an emergency room. Patients are stabilized for transport with the provision of first aid and basic life support.

Health Promotion

The inmate patient population is often underserved with limited healthcare access in the community. They enter the correctional system having made poor lifestyle choices and often have little knowledge of how to manage chronic conditions.  Therefore, correctional nurses have a major role in promoting heathy lifestyle choices while educating the patient population at every encounter.

Patient Advocacy

Healthcare is not the primary mission of correctional institutions. Security concerns and community safety may vie with an individual patient’s healthcare needs. Correctional nurses negotiate the security system and collaborate with officer peers to meet patient health needs within system constraints. They act as patient advocates through these efforts.

Care Coordination

Correctional nurses coordinate patient care within a system arranged for other purposes. Barriers to care must often be overcome. Standard security constraints such as restricted movement or limited personal items can inhibit continuity of care. Correctional nurses must creatively navigate the system to coordinate appropriate care.

Along with the above roles, correctional nursing practice is a merger of multiple nursing specialties: Occupational health, emergency nursing, acute care, community health, psychiatric care, geriatrics, women’s health, adolescent health, palliative and end-of-life care.  A correctional nurse must be prepared to deliver a full menu of assessment and interventions within the security perimeter; knowing when a patient needs to be transported to an advanced level of care or specialty. This can be a daunting task for even the experienced professional.

Although I caution new nurse graduates to pick their first correctional nursing position with care; it can be done. With an extended orientation and good management support, many new nurses have made correctional nursing their first specialty.

Do you have a story about the various roles of correctional nursing? Share your thoughts in the comments section of this post.

*Affiliate Disclosure: I am grateful to be of service and bring you content free of charge. In order to do this, please note that when you click links and purchase items, in most (not all) cases I will receive a referral commission. Your support in purchasing through these links enables me to keep this blog going. Thank you!

Patient Safety and Correctional Nursing Care

Traffic cones and hardhat. Road sign. Icon isolated on white bacAccording to the Wall Street Journal, enough Americans are kills by medical errors each week to fill four jumbo jets. Patients are rarely told of errors made during their care and the same errors often happen over and over again. A third of hospitalized patients experience a medical error and 7% are permanently harmed or die as a result of an error. The annual cost of medical errors has been reported to be upwards of 17 billion. How about in our own specialty? How can we reduce errors to improve our patient outcomes and reduce costs?

Correctional nurses have the most contact with the correctional patient population and, therefore, improvements in the way nursing care is delivered can improve patient safety in our setting.  A good place to start is by considering the application of patient safety principles developed for traditional health care settings to the organization and delivery of nursing care in our setting.

The Institute of Medicine (IOM) commissioned a consensus report on nurse activities toward patient safety in 2003. KEEPING PATIENTS SAFE: Transforming the Work Environment of Nurses provides expert recommendations for nurse-workforce efforts toward patient safety that can be applied in the correctional setting. Here are some key recommendations that apply to our specialty:

  • Fatigue leads to errors: Nurses should not work longer than 12 hours in a 24-hour period and in excess of 60 hours per 7-day period. Airplane pilots have a limit on number of hours in the air. Nurses make decisions that affect the health and safety of their patients. Limiting mental and physical fatigue is just as important in our field.
  • Busyness leads to errors: Nurses should have limited involvement in non–value-added activities, such as locating and obtaining supplies, looking for personnel, completing redundant and unnecessary documentation, and compensating for poor communication systems. Improving systems to reduce nurse involvement in these activities will free up time for important patient safety functions.
  • Communication reduces errors: Systems for communication among and between health care disciplines will reduce communication gaps and increase patient safety.
  • Orientation and training reduces errors: The onboarding and ongoing education of nursing staff is vital to increase patient safety in the fast-paced changes of health care. Attention to the development of all new and incumbent staff members will reduce error.

Can we improve patient safety in correctional healthcare? This short list is a good place to start. What is your facility doing to reduce medical errors? Share your thoughts in the comment section of this post.

This post originally appeared in the Essentials of Correctional Nursing blog.

Photo Credit: © Aleksandr Bedrin – Fotolia.com

Multi-Dose Vials: Risk and Reality in Corrections

Syringe and vialsCheri was delighted to land her first nursing job in the county detention center close to home. She was an LPN and the only nurse on night shift for an average population of 300 mostly-male inmates. The night shift nurse gives the morning insulin for any diabetic inmates at 5am just prior to breakfast. This is always a time-pressed situation. The line officer is eager to get to shift report and the inmates don’t want to miss the best selections in the chow line. Cheri hadn’t much experience with drawing insulin from vials as her school clinicals were in LTC facilities and they used insulin pens. The new patient in the line had an order for both Regular and NPH insulin that required mixing. She picked up the Regular insulin and noted that the label indicated U-100. She interpreted that to mean there were 100 units of Regular insulin in the small vial and began to draw up the patient’s dose…..

If you are a long-time nurse, especially in the correctional setting, you may be surprised to learn that drawing up insulin from multi-dose vials and mixing insulins in a single syringe are no longer as common a practice in traditional health care settings. Individual insulin pens and premixed pre-measured syringes have frequently replaced nurse calculations in administering insulin for diabetic management. Nurses new to our specialty may have little experience with what we consider a common practice. Fewer safeguards and, often, minimal oversight of staff practices can lead to a variety of clinical errors.

The Institute for Safe Medical Practices (ISMP) reviewed errors in using insulin vials. They fell into the following categories. Consider your own setting and multi-dose vial practices and evaluate how many risks are currently present:

  • Dosing errors: In the example above, Cheryl assumed that U-100 was the total number of units in the 3ml insulin vial. This can happen when staff are not familiar with insulin characteristics and standard concentrations. Dosing errors can also result from using a syringe labeled in ml rather than units (mixing insulin syringes with parenteral syringes).
  • Look-alike vials: Vials of different medications can appear similar-especially if the nurse is distracted or time-pressured, as Cheryl was.
  • Unlabeled syringes: In some settings nurses may draw up medication in syringes prior to direct administration. If syringes are not labeled, a mix-up can result in medication given to the wrong patient.
  • Beyond expiration: If expiration dates are not written on an opened multi-use vial once it is punctured it may be used when it is no longer safe or potent.
  • Cross-contamination: Because a vial can be accessed by multiple practitioners for many different patients over several weeks, there is great chance for contamination. This is more common that you might think. One study found that 25% of practitioners have re-entered a vial with a contaminated needle. Recent news from the Arizona and Connecticut show that this continues to be an issue in the correctional setting.

Multi-dose vials, in general, are a source of considerable medication error. The most common uses for multi-dose vials in the correctional setting are insulin, PPD solution, and vaccine. Here are some standard protocols for multi-dose vial use in any setting:

  • NEVER reinsert a used needle into a multi-dose vial.
  • Whenever possible, have a separate vial for each patient. Clearly label with the patient name and organize vial storage to maximize easy identification.
  • Medication in vials are good for 28 days and should be labeled with the expiration date once opened for use (unless the manufacturer information specifically states otherwise).
  • Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial.
  • Discard multi-dose vials if sterility is compromised.
  • Many medications provided in multi-dose vials also need refrigeration. Be sure that the medication refrigerator is kept at the proper temperature. “Vaccine clinics” can be of particular concern as vials may be removed from refrigeration for extended periods of time which can jeopardize the integrity of the vaccines.
  • Follow facility regulations regarding sharp movement, if a pre drawn syringe, and multi-dose vials are used, they should be transported in a locked container with access to a disposal system at the point of administration.

Unfortunately, safeguards were missing in Cheri’s insulin administration situation. Although her new patient received an overdose of insulin, he recovered from a significant hypoglycemic event with quick treatment and a day of evaluation in the infirmary. Could this situation happen in your facility?

Share your thoughts on the dangers of insulin administration from multi-dose vials in the comments section of this post.

Photo Credit: © antpkr – Fotolia.com