2024 IAPS Safety Story (Near Miss or Close Call) Award Winners, The Emeritus Nurse Program, Penn State Health Milton S. Hershey Medical Center

The Emeritus Nurse Program
Penn State Health Milton S. Hershey Medical Center

The Emeritus Nurse Program has arguably prevented harm in hundreds of vulnerable patients. Emeritus nurses (E-RNs) are seasoned and often retired registered nurses who work on a per diem basis, primarily supporting the bedside nursing staff in reviewing and delivering discharge instructions directly to patients. Originally created and launched as an innovative staffing strategy, the E-RNs have emerged as safety champions. They have documented over 215 near miss events related to discharge instruction errors. These great catches are frequently found in conversation with the patient and through investigation into the electronic health record, including home medication reconciliation, inpatient orders, and physician progress notes. Because their time is dedicated to this work, E-RNs have been able to stop and resolve many discharge medication errors related to duplication, omission, and appropriate dosing. Below are several examples of specific patient interactions that highlight their nomination for the Safety Story award.

On the surgical care unit, an E-RN identified that in the written instructions the provider stated the patient would be discharged on Lovenox [an anticoagulant that helps prevent blood clotting] injections. However, when the medication list was reviewed, Lovenox had not been ordered. The E-RN contacted the physician directly to clarify the orders. The provider placed the correct orders and the patient was given correct discharge information with the correct prescriptions. It could have been very dangerous had this been missed, as this postoperative patient was likely at high risk for a pulmonary embolism, stroke, or heart attack.

On the medical oncology unit, an E-RN noted that a patient was ordered sliding scale insulin and nitroglycerin tablets on discharge. The sliding scale did not have clear dosage times, and the nitroglycerin tablets did not clarify when to stop taking the medication and call 911, especially if their chest pain continued. The E-RN contacted the covering physician, who updated the orders, and a new discharge document was printed. Both these medications require this key information to keep patients safe at home. Unknown insulin administration times could lead to hyper- or hypoglycemia [high or low blood sugar, respectively], and not notifying 911 could delay lifesaving carey.   

Other examples include rectifying double orders of narcotics with differing doses, clarifying orders for medications with conflicting diet instructions, and even hand-delivering discharge instructions to patients in the main lobby after they were forgotten accidentally. Even small corrections to discharge instructions and understanding can prevent future harm, including readmission or death.   

While not all 215 examples can be provided, it is clear that E-RNs utilize their nursing experience to reduce harm events by reviewing discharge instructions away from a traditional assignment and independently requesting changes as needed from providers. In a time when technology can be slow, incomplete, complicated, and expensive, E-RNs have been able to intervene as a final safety barrier in the continuum of care. Discharge can be a confusing time for patients and their families, but E-RNs’ knowledge and diligence have been a true gift to them and the organization over the last year. 

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