Skip Ribbon Commands
Skip to main content

Risk Advisors Newsletter Archive


2013 NSO Risk Advisor

Feature Article: How did I make that mistake?
A nurse pulls a heparin vial from a medication cart. She looks at the label, fills the syringe, and then injects the infant-with the wrong drug. The infant dies.
This true example happened when a cart was inadvertently stocked with heparin vials containing 10,000 units/mL instead of the usual 10 units/mL. Part of the problem was that the labels looked similar; in fact, the abundance of these types of cases has led to a change in heparin labels effective May 2013. But a likely contributing factor is "inattentional blindness," which refers to the failure to see something that is unexpected. In the heparin example, the nurse wasn't expecting an incorrectly labeled vial, so she didn't see it.

Feature Article: How to prepare for a deposition

Using an electronic prescription system, an advanced practice nurse (APN) orders penicillamine for a 9-year-old patient with a positive test for Streptococcus. The APN meant to order penicillin, the antibiotic, not penicillamine, the chelating agent. The error wasn't caught for 2 days when it was noticed the patient wasn't improving.
This true example could easily occur with a busy APN. An example of one way it might have happened is that when the APN reviewed the order before signing off, he or she misread the name of the drug. In that case, a likely contributing factor might have been "inattentional blindness," which refers to the failure to see something that is unexpected. In the penicillin example, the APN wasn't expecting an incorrect drug name, so didn't see it.

2012 NSO Risk Advisor

Feature Article:   Improving health literacy improves patient outcomes
Imagine telling a postoperative patient how to take his pain medication and sending him home only later to find out he ended up in the ED because he overdosed on the medication, taking six pills instead of two. His family wants to sue you and the hospital for not giving him the right instructions. You recall that after giving him his discharge instructions he shook his head indicating "no" when you asked, "Do you have any questions?" What happened?

Feature Article:   Are you competent in cultural care?
A diverse group of people call the United States home, so advanced practice nurses (APNs) routinely encounter patients of different cultures in their practice. But how confident are you in your ability to meet varied cultural needs? Your competency is key, not just to achieve excellent patient outcomes, but also to protect yourself from possible litigation.

2011 NSO Risk Advisor

Feature Article:   What you need to know about nurse practice acts

With your busy schedule, you may not have had the time to read your state's Nurse Practice Act (NPA) lately. Practicing within the NPA is perhaps the single most important step you can take to protect yourself. Here's why the NPA is so important and what you need to know about it.

2010 NSO Risk Advisor

Feature Article:   Play it safe with Bar Code Medication Administration

Designed and used correctly, bar code medication administration (BCMA) can improve patient safety by reducing errors. But it offers this benefit only if used properly. Taking shortcuts or creating workarounds to save time or fix glitches in the system isn't only unsafe for patients, but may also expose you to serious legal consequences.
Feature Article:   Create a Culture of Accountability
Advanced practice nurses (APNs) are constantly looking for ways to improve the quality of service they provide to meet the demands of the public and close quality gaps in healthcare systems. The key to providing high-quality care is starting with a culture of accountability, which can help reduce the overuse, misuse, and underuse of resources; increase use of clinical guidelines and evidence-based practice; improve patient care outcomes; and ultimately create a continuous learning organization.


Call 1-800-247-1500

Mon – Fri, 8am – 6pm ET.