Proposed Law Would Revoke Licensure for Medication Errors

11 May

Mat Keller headshot

By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist

“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”

While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.

As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”[1] 

Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.

Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address.  It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.

As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).

Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors.  How would you change the language to better prevent errors?  Share your thoughts in our comment section below.

[1] Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.

12 Responses to “Proposed Law Would Revoke Licensure for Medication Errors”

  1. Mary Kirsling May 11, 2015 at 1:13 pm #

    The.worst.idea.ever. We have a problem now with underreporting. Recipe for disaster. How do you learn from mistakes unless they are reported. This will seal the deal. Been a nurse for 44 years. For all of you infallible self righteous legislators, why do you think erasers were invented? For all of us fallible human beings, that’s why.

    • P. Watkins RN, BSN, PHN, CLNC May 11, 2015 at 2:41 pm #

      Unbelievable !! I totally agree w/ Ms. Kirsling! This law also includes under medicating ~ where no harm was done. Hopefully, some one will do the right thing and let this bill expire!

    • Ron Ayers, RN, MSN May 12, 2015 at 10:42 pm #

      I too agree with Ms. Kirsling! Underreporting will get totally out of hand if nurses face losing their license and valuable lessons will be lost. If serious harm is caused to the patient, then the South Carolina Board of Nursing should be responsible for any discipline that needs to occur, including possible licensure revocation on a case by case basis. Previous mistakes should also be considered as well as the lack of any previous ones.

  2. Tina Stone, Supervising RN May 11, 2015 at 5:02 pm #

    I ask the law makers to walk beside an RN for a day truly see and feel what a nurse does, then have a conversation about this “proposed law”. Maybe 1:2 ratio for bedside floor nursing would be a solution? OR can we say another ” nursing shortage”.

    We care !!!!!

  3. Tim Gilmore, RN, MHA May 12, 2015 at 3:24 pm #

    Medications errors always have the potential for a bad outcome. Bad medication errors have the potential for tragedy. Having said that, even the best systems/medication ordering, dispensing and administration have flaws. We always need to look to the systems first. Yes, humans bypass systems intentionally or inadvertently, but his misguided solution will not help in the least.
    RN for 38 years.

  4. cynthia kuehn May 12, 2015 at 4:42 pm #

    I feel that is an inappropriste response to a ststme failure. To hold oetdons responsible g I r s failed process, is avoiding the elephant in thr room.The only thing thus bill will promote is a dectease in bedside nursing, which is already an issue.

  5. Vickie Drafts May 13, 2015 at 7:03 am #

    And our tax money pays for your thinking….sad. How about someone look into the hours a nurse puts in and the ratio of patient to nurse. ERRORS OCCUR WHEN A NURSE IS GIVEN TOO MANY PATIENTS AND TOO MANY HOURS WORKED. Put on some scrubs and follow us for a 12 hour shift before you start throwing around suggestions.

  6. Ag Castor, MN, CRRN, CCM May 13, 2015 at 9:42 am #

    I’m with the, “Only if you make mandatory 3:1 patient:bedside RN ratios in all facilities. No? OK, then, bad idea, we’re done. “

  7. Jane Pattinson, RN May 15, 2015 at 10:54 pm #

    I’ve been an RN for forty-five years in two states and a variety of hospital nursing settings—Any nurse who has worked for ay length of time and claims that they have never made a med error is probably a liar. How are they planning to run hospitals in South Carolina without nurses? That’s the only outcome possible under the terms of this proposed legislation.

  8. Valerie May 18, 2015 at 5:16 pm #

    Then they can train the certified NA as a Medication Assistant and just take another Clinical Nursing task away and then Nurses are no longer responsible for medication errors. I really think that South Carolina has bigger problems to deal with than this, but don’t get me started!!!

  9. Joanne June 8, 2015 at 9:16 pm #

    This is an example of poor critical thinking. It’s sad that we pay these people a salary.

  10. Jacqueline Galante June 30, 2015 at 9:25 pm #

    My heart and prayers go out to this family and all they have suffered. Clearly, this tragic event should NEVER have happened, but revoking a nurses’ license for making a medication error is NOT the answer. Yes, there should be stricter consequences for this particular nurse, but she is one person. I believe there are a small percentage of people in every industry (not just nursing) that NEVER learn from their mistakes. All health care providers should NOT pay the price.

    This legislation will undermine the “culture of safety” that is critical to reducing medication errors. If this legislation is not revoked, sadly we can all count on errors to increase. Many will NEVER be reported, and efforts to learn about them, and devise ways to prevent them from happening will be futile.

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