Safety First Blog

The Wrong Dose: A True Story of Medication Error

Safety Nurse sat down with Margo, a fantastic oncology nurse, who talked about the night she gave a patient too much insulin, and he coded. He lived, and Margo is still at the same job. The hospital where she worked supported her and included her in a Root Cause Analysis of the event. Margo is now a well-respected nurse leader at her place of work. In the interview, she opened up about how the error went down, and we talked about the inevitability of error.

Click HERE to read the full story.

You can listen to the podcast of the interview at THIS link on iTunes

Or you can listen to it on Stitcher

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.

Safety First Blog

I've Been "Invited" To A Root Cause Analysis, Now What?

I’m blogging for allnurses!

allnurses is the leading social-networking site for nurses and nursing students. People from all over the World come to allnurses to communicate and discuss nursing, jobs, schools, NCLEX, careers, and so much more.

Click HERE for an article about what to expect from a Root Cause Analysis

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.


Safety First Blog

The Origin Story of Safety Nurse: How I Got Here. Pt 1

I’m blogging for allnurses!

allnurses is the leading social-networking site for nurses and nursing students. People from all over the World come to allnurses to communicate and discuss nursing, jobs, schools, NCLEX, careers, and so much more.

Click HERE for an article about the origin story of Safety Nurse!

The origin story of Safety Nurse, who, garbed in turquoise scrubs, a white cape, a 50’s style nursing hat and sensible, orthopedic shoes, walks hastily through the galaxy providing assessment skills, education, wound care and safe medication administration!

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.

Safety First Blog

Rose is learning English ~ Update on Safety First Nursing in Haiti

Listen to the podcast HERE

Or you can listen to it on Stitcher

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.
Rose is learning English ~ Update on Safety First Nursing in Haiti

Welcome back to Safety First Nursing, the home of the patient safety specialist. It is my passion to bring you education, research and resources supporting patient (and nurse) safety. It’s been a busy week preparing for my first seminar for Vyne Education (for 6 CEU!). I will be facilitating in Indianapolis, Cincinnati and Columbus – a whirlwind tour of the Midwest (but I get to see my mom!) and I get to interview Lorie Brown, a nurse who is also an attorney. I am really looking forward to sharing info about her story and how she can support nurses who have to go before boards of nursing.

I am counting the days until school starts again (18, in case you were wondering). My kids have been going to Ultimate Frisbee camp, and I have been plugging away looking for venues to get my message out there. My mission is to bring the best patient safety information to nurses around the globe, hoping to prevent future incidents of harm. My business coach suggested I look for speaking engagements; so we are working on that – if you know of anyone who would like me to talk about patient safety, please contact me! And a free bar of soap from Essential Journeys to anyone who meets with me in person to discuss how SFN can support patient safety for you or your organization!

This week will be a short article– just updating you on Rose’s adventures with English school. As you may know, Rose is the Haitian student that SFN is sponsoring through nursing school in partnership with Consider Haiti. If you want to know more, you can read previous blogs about this incredible adventure.


The class, and nursing school this fall, are in Saint-Marc, which is about a 45 minutes “drive” from where Rose lives. I put drive in quotes because it is really a wild ride. There was a ride at Disney World called Frog and Toad’s wild adventure – driving in Haiti reminds me of that. Everyone drives as fast as they can, honking and veering wildly around cattle, goats, people and giant pits or rocks that appear in the road out of nowhere. The road is used by cars, “tap taps” (cars that have been painted with bright colors, operating like taxis)

busses, trucks, pedestrians, scooters, motorcycles (motos), bicycles, donkeys, horses and anything else you can possible think of. These vehicles are loaded with a creative and unbelievable amount of people and goods. There are no streetlights or street signs, no guard rails, no sidewalks.

Accidents are common and can be deadly. One day last fall when I was working at the clinic Esperance, 3 boys were brought in after being in a horrible motorcycle accident. I have included photos from both my trips to Haiti so you can see the eclectic mix of transportation.

The fewer back and forth trips Rose has to make the better. She doesn’t know anyone in Saint Marc other than her fiancé and his family and she doesn’t feel comfortable staying with them. We are looking for a room for her to rent so she won’t have to go back and forth every day. Nursing school is from 2p-7p M-F.

I asked Rose to share something interesting about Haitian culture. She shared with me that every January, families in Haiti cook pumpkin soup or soup joumou to celebrate Haitian Independence, which was won in January of 1804. Prior to that, Haiti had been colonized by France and they had forbidden Haitian slaves to eat any foods with pumpkin in them. To Haiti, pumpkin symbolizes freedom. There is a documentary about Haitian Pumpkin Soup called Liberty In A Soup by Dudley Alexis, a Haitian-born Miami filmmaker.

My most recent email from Rose was August 6th, I asked her about nursing in Haiti, and about the amount of diabetes in Haiti, as well as medication management/polypharmacy. Remember that the translation is mainly google translate, with some help from Maggie (who founded Consider Haiti) – so I do my best to keep the flow of her words but make it understandable.

Hi Miss Kristi Miller,

That is Rose. How are you? How is your family?

I thank you for your last letter. Thanks for the pictures too. You and your family are really nice.


I am pleased to be able to practice English together, which will allow me to go faster in learning the language.


To answer you about nursing in Haiti, I contacted a nurse and asked about it. He told me that nursing in Haiti is no different from other places. It is such a universal thing that there may be some minor deviations in how to teach this science or practice. The main role of the nurse is to execute the Dr.s orders, because the nurse has limits and must stay within this limit.


Abel’s father has had diabetes for 7 years and it is really sad for him because he has suffered all his life. He takes 8-10 daily medications, which is not easy because many times this person can be discouraged and decides not to continue the treatment. Talking about diabetes reminds me of my father, who suffered much from it.

Sincerely, I do not have much information about this disease especially on the type of diabetes. I know it makes the patient sick on some parts of the body that don’t ever heal. It often happens that the doctors have to cut off a limb of the infected person. I would like to know how many types of diabetes there are, I would also like to know if American doctors cut off the legs of people with diabetes. I hope my nursing studies will support my ability to relieve the suffering of people with diabetes and help in the fight against illness.

Rose included some great pictures of her classroom and of her textbook – I am looking forward to getting my first note from her in English. October and nursing school will be here before we know it! To get the latest updates on Rose, as well as info on new patient safety education, research and resources, sign up for the safety first nursing newsletter.


Safety First Blog

Safe Medication Administration: Following the Checklist Manifesto

Listen to the Interview on iTunes

Or you can listen to it on Stitcher

Did you like this content? Donate TODAY to support Rose Katiana on her journey through nursing school, and let me know what other content you want covered.
Welcome to Safety First Nursing and my fourth blog/podcast. This one is just a short summary of my first continuing education activity: Safe Medication Administration: Everything you need to know to improve your practice. You can find the full-length video, podcast and transcript on my website, but just in case you don’t have an hour, I really wanted to give you the checklist info, because that’s the pay-off.

The mission of SFN is to support the physical, psychological and emotional safety of patients and nurses through education, research and resources. I started SFN after being involved with a patient safety incident at my former job, and I was actually going write on that for episode 4, but I found myself being drawn to something light and easy. After the huge amount of work I put into episode 3, on continuing education, including a review of sites that offer patient safety courses, I needed a break before the psychic challenge of finding a way of telling you about the patient safety incident I was involved in. I want it to be honest, and I want you to still trust me when I am done. I am not sure that is possible, but it’s my goal, so stay tuned, and I will very much look forward to having it done and out there so I can hear back from you. What I really hope to do is start a conversation about nurses involved in errors, near misses, mistakes and “incidents”. I want to talk about the emotional and psychological impact being involved in all that stuff lays on you – it can be incredibly painful, and incredibly isolating – we don’t want to talk about it because we are ashamed, because we are worried someone will judge us. Because we know, deep down, that the first thing most nurses think when they hear someone else made a mistake is, “she wasn’t trying hard enough” or “bad nurse”. Golly, I can’t wait to get started! But seriously, I know it will be healing to write about it…just need to get the first words on the page.

I’m going to offer a wide variety of presentations on safety, some of them for patients and nurses, but also some for anyone interested in the concept of safety. Some of the presentations on my website are geared towards nurses looking for high-quality continuing education on the topic of patient safety – like the one on safe medication administration: everything you need to know to improve your practice, which is available for one CE, and one on how to do Root Cause Analysis is coming soon. Others, like episode #2 on my relationship to nursing in Haiti would be of interest to anyone interested in patient safety. I’m gearing up to do some interviews, and very much want to hear from you about topics you are interested in – do you have something you would like to share? Please contact me through my website at, or email me at, I am on twitter @safetyfirstNRS, facebook, linked-in and instagram.

So I am going to give you a quick summary of the continuing education activity about safe medication administration and then direct you to all the good resources and checklists I have created. The activity is worth 1 CE and is available as a podcast, video and transcript – and should take just over an hour to listen to or watch. In it I review the impact of medical error on the healthcare system, including the new proposition that medical error may be the third leading cause of death if we look at the numbers from a fresh perspective. I also talk about why medication errors occur, and how nurses are involved, as well as the impact on patients, families and healthcare providers. I talk a great deal about systems issues, with the goal of helping people understand that error is going to happen, no matter what we do to prevent it, and the best we can hope for is to prevent harm. The best part of the study is the discussion of solutions and strategies focused on preventing harm. The strategies focus on what systems theorists call “the blunt end of the stick” – the end where changes in policies, technology and leadership can prevent the likelihood an error will occur; as opposed to “the sharp end of the stick” – the end where nurses actually make mistakes with sometimes horrible consequences. Firing the nurse has been the traditional response, with little effect on error rates. I present definitions (confusing and conflicting), how error is measured (poorly and inconsistently) and the complexity of the task of medication administration (truly mind-boggling). James Reasons theory of “Swiss Cheese” is discussed, with illustrations to show how plugging the holes in the cheese can prevent harm from error. Using case studies from literature, and the most up-to-date resources from the best patient safety organizations (see my resource list), I present how a change in perspective from blame and shame, to one of a just culture can reduce the risk of harm to patients. I present several tools to assess blameworthy behavior, an important first step in dealing with error, as well as multiple checklists that address the many holes in the “Swiss Cheese”. I have been reading Gawande’s “The Checklist Manifesto” (2010) and have take his advice to make some checklists. There is even a checklist for Nurse educators, based on my 2016 publication: Educational Strategies for Reducing Medication Errors Committed By Student Nurses: A Literature Review from the International Journal of Health Sciences Education

I hope you will use the resource list, the checklists, the references and all of the information presented in the full continuing education activity. Most of all, I hope you will participate in some discussion! I would like to know what I left off the checklists, what I missed, what I messed up, and what I can add to support patient safety. As your ideas and suggestions come in, I will make edits and revisions as needed and send out new and improved checklists as we co-create a safer world for patients.

Wanted to give you an update on Rose, the wonderful woman that SFN is sending to nursing school. You may recall from episode 1 about Haiti that Rose is an orphan. She shared with me that her mother died from complication due to diabetes and hypertension. During my two visits to Haiti as a nurse at multiple mobile clinics, about 50% of the people we saw had some combination of diabetes and hypertension. You can’t tell someone whose main diet is starch to eat “low carb” – protein is a rare and highly valued commodity, and not something widely available to Haitians. You also can’t expect them to reduce sugar and salt intake – two relatively inexpensive and widely available substances that make a Haitian’s day a little brighter. And don’t get me started on medications – when you don’t have a regular food source, purchasing medications isn’t on your to-do list. Rose’s mother would be alive if she lived in the US, because we could feed her good food, give her some metformin, and some ACTZ and get her blood pressure down. It is so frustrating. Her father died of a broken heart. He was a farmer and often worked in the fields around the clock ensuring his crops had enough water to grow – irrigation is a HUGE issue in Haiti – the weather is amazing for growing plants, but there is no way to irrigate the fields – no pumps, no way to dig wells. He became paralyzed – still getting the full story – and slowly wasted away lying in bed, wishing he was out in the field working. Last but not least, in episode 1, Rose told us a story about her friend Sandra – the little girl she helped by buying her some clothes. I asked about Sandra and found out she died in the Earthquake in 2010. I wish I had some good news. I guess the only good news is that Rose has some hope. She is getting English lessons, and will be going to nursing school in the fall. Remember, SFN donates 10% of all profits to Rose’s education through Consider Haiti. I hope you will consider a donation as well.


Certified Professional in Patient Safety – CPPS

Agency for Healthcare Research and Quality

Understanding Patient Safety – 2nd Edition, Robert Wachter

Institute for Healthcare Improvement – Global Trigger Tool

AHRQ Patient Safety Indicators

ProPublica Patient Safety Community

Medically Induced Trauma Support Services

Wall of Silence – The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans

CANDOR toolkit – AHRQ

forYOU team – University of Missouri

Show Me Your Stethoscope

National Patient Safety Foundation

Institute for Safe Medication Practices

National Coordinating Council for Medication Error Reporting and Prevention


Medication Error Reporting

Lippincott Procedures – Safe Medication Administration

Institute of Medicine (is now called The National Academies of Science, Engineering and Medicine; Health and Medicine Division)

North Carolina Board of Nursing Complaint Evaluation Tool

The Professionalism Pyramid

The Patient Advocacy Reporting System

Centers for Medicare and Medicaid Services (CMS)

Quality and Patient Safety – State Regulations by state

Policy and Advocacy for Nurse Staffing Ratios – American Nurses Association

The Joint Commission

The American Association for Accreditation of Ambulatory Surgery Facilities

The National Quality Forum

The Leapfrog Group

Partnership for Patients

Medication Without Harm – the World Health Organization

Tort Reform

The Checklist Manifesto

Measuring and Benchmarking Clinical Performance- AHRQ

HRSA Data Warehouse

HRSA Uniform Data System

National Center for Quality Assurance



IHI – Leadership Guide to Patient Safety

Crew Resource Management


Failure Mode Effects Analysis

Root Cause Analysis

AHRQ Survey on Safety Culture

Safety Attitudes and Safety Climate Questionnaire

MEDMARX Reporting

Incident Reporting to ISMP


Medications At Transitions and Clinical Handoffs

IHI – SBAR Techniques for Communication


Consumers Advancing Patient Safety

Patients for Patient Safety – WHO

Speak up – The Joint Commission

Teach Back – AHRQ

Ask me 3 – NPSF

What should patients do to help make care safe? NPSF