Danielle was a new nurse with only 6 months experience, working night shift in the ICU. She loved her job, but didn’t yet feel confident.
One night Danielle was assigned to an 81 yr. old female who was found down at home by her granddaughter. She had suffered a massive stroke and never regained consciousness. Now she was intubated and unresponsive. The doctor came in, an ICU intensivist, examined the patient and barked an order at Danielle to give Fentanyl 950 micrograms (mcgs) IV. He had an air of authority and clearly was used to having his orders carried out without question. Even so, it sounded like an unusually large dose and Danielle questioned the order “Fentanyl 950 micrograms? Isn’t that a large dose?”
In nursing school, Danielle had done a rotation in PACU where only 25 mcgs at a time were ordered, with a maximum amount of 100 mcgs. The doctor said “She has irreversible brain damage and is suffering even though she can’t communicate. High dose fentanyl is a common treatment for patients with severe brain injury. Don’t worry, she’s on a ventilator. It’s not like she’s going to stop breathing”.
Hesitantly, Danielle looked towards her Charge Nurse, who was nearby and listening. He shrugged and nodded his assent. Instead of doubting the doctor, Danielle was now doubting herself. She thought, “Well, I seem to be the only one here who is questioning this order. I know things in the real world are often different than what I learned in nursing school. He’s the doctor, so it must be safe”. Danielle gave the Fentanyl. Within minutes, the patient went into a lethal arrhythmia.
This is a fictional story, but it is based on an even more chilling true story.
While most nurses will read this and think “I would never, ever do that”, in Columbus Ohio’s Mount Carmel hospital, over 25 nurses have been cited by the Ohio Board of Nursing for failing to question similarly potentially lethal doses of Fentanyl (500-2000 mcgs).
All of the fentanyl orders were ordered by one doctor, a Dr. Husel, and they resulted in 25 patient deaths. Dr. Husel is being charged with manslaughter, and the nurses and pharmacists involved are currently under investigation.
How could this happen? Dr.Husel is clearly a serial killer , but why would a nurse ever administer a potentially lethal dose of fentanyl?
Bias of Authority
When a nurse receives a doctor’s order, the nurse often automatically attributes bias of authority to the doctor. Bias of authority is the tendency to attribute greater accuracy to the person in authority. According to the New York Times, “(Dr. Husel) provided explanations for the high doses of fentanyl that satisfied the nurses at Mount Carmel, some of whom were new to the job”.
Bias of authority does not only come into play between doctors and nurses. It can take place between nurses. An example is when a nurse double checks a medication calculation with a more experienced nurse or charge nurse. Let’s say a nurse calculates the rate for a heparin drip and arrives at a rate of 13 mg/kg/hr. The charge nurse quickly calculates the rate and comes up with 23 mg/kg/hr. The first nurse knows that one of them is wrong, and assumes it must be herself, so she runs the IV heparin at 23 mg/kg/hr instead of both nurses independently recalculating the rate.
Conformity Bias
At Mount Carmel, there was also conformity bias. The nurses took their cues from their surroundings where multiple nurses had previously administered high doses of fentanyl. The message had been sent that it was OK to give patients with terminal diseases extremely high doses. After all, the doctor ordered it, the pharmacist dispensed it, and other nurses administered it. This amounts to a great deal of pressure to conform. This is not to excuse the nurses’ behavior, but it is to offer an explanation for how otherwise good nurses make poor decisions.
Bias of Expectation
Another type of bias is seeing what you expect to see. One nurse holds up a syringe with insulin and says “10 units of Lispro”. The second nurse glances at it, expects to see 10 units, and agrees. Because of bias of expectation, it is better to draw up the insulin in the presence of the second nurse, and then ask, “How many units are there?”
Responsibility Lies with the Nurse
Even when a doctor orders an incorrect dose or medication, or when a pharmacist dispenses an incorrect dose or medication, the nurse who administers the drug has responsibility. Nurses have every right to question a doctor’s order. There are times when a nurse should not follow a doctor’s order. If an order is given that contradicts the facility’s policy or best practice guidelines, nurses are ethically bound to question those orders. Nurses are culpable for their part in the error when mistakes are made.
Be sure to know which drugs your facility has designated as high-alert drugs. Also know your reversal/rescue agents, such as naloxone (Narcan) for sublimaze (Fentanyl) and other opiates, and flumazenil (Romazicon) for midazolam (Versed) and other benzodiazepines.
Just Culture
Every nurse fears making a medication error and harming a patient. Giving medications is one of our most critical duties.
Nurses should feel safe speaking up and questioning. Doctors should appreciate the efforts to keep patients safe, and hospitals should encourage a culture where errors and near misses can be safely reported.
