Background Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses’ autonomous decision-making. Objectives To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. Methods A survey of nurses’ experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. Results The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. Conclusions Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

Background Medical errors are common in intensive care units. Nurses are uniquely positioned to identify, interrupt, and correct medical errors and to minimize preventable adverse outcomes. Nurses are increasingly recognized as playing a role in reducing medical errors, but only recently have their error-recovery strategies been described. Objectives To describe error-recovery strategies used by critical care nurses. Methods Data were collected by audio taping focus groups with 20 nurses from 5 critical care units at 2 urban university medical centers and 2 community hospitals on the East and West coasts of the United States. Transcript content was analyzed as recommended by Krueger and Casey. Results Analysis of focus group data revealed that nurses in critical care settings use 17 strategies to identify, interrupt, and correct errors. Nurses used 8 strategies to identify errors: knowing the patient, knowing the “players,” knowing the plan of care, surveillance, knowing policy/procedure, double-checking, using systematic processes, and questioning. Nurses used 3 strategies to interrupt errors: offering assistance, clarifying, and verbally interrupting. Nurses used 6 strategies to correct errors: persevering, being physically present, reviewing or confirming the plan of care, offering options, referencing standards or experts, and involving another nurse or physician. Conclusions These results reflect the pivotal role that critical care nurses play in the recovery of medical errors and ensuring patient safety. Several error-recovery strategies identified in this study were also reported by emergency nurses, providing further empirical support for nurses’ role in the recovery of medical errors as proposed in the Eindhoven model.