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From our readers…Three elephants for safety


A familiar safety protocol in hospitals is the time-out. Mandated for many invasive procedures, this “work stop” ensures the right site, right procedure, and right patient are verified and confirmed by at least two practitioners before “scalpel touches skin.”

Following the five rights of medication administration is equally important to ensure nurses maintain zero tolerance for medication errors. But while two or more practitioners must confirm the details of a time-out, only a single nurse is ultimately responsible for medication safety.

Yet, it’s surprising how little time we actually take confirming a drug’s name, dose, and concentration. Try counting the next time you grab a vial, IV bag, medication packet, or set an IV pump. Typically, we spend no more than a single second confirming that what we’re looking at, is exactly what we expect it to be.

On more than one occasion, I can remember a drug or dosage suddenly “changing” when I stopped for a “Three-Elephant Time out.” Sounds silly, but this full three-second pause enables me to focus on one thing, and one thing only—the drug in my hand.

Of course, if we all worked at Utopia General, we’d never feel rushed, we’d never be interrupted, and extra support staff would be available at a moment’s notice. In such a place, even new nurses would never feel compelled to practice beyond their comfort zone of safety.

But real nursing is anything but idyllic. Over the years, an insidious accumulation of tasks and duties have been “grandfathered” into our practice. This has resulted in nurses more likely to rush in order to complete the growing list of responsibilities. Even experienced nurses who are masters at multitasking can feel like they’re flying by the seat of their scrub pants when the phone calls start, the admissions arrive, families get anxious, and physicians want answers. It’s easy to get swept up into a cycle of rushing that opens the door to potential errors.

Additional risks occur from the unwitting errors or policies of others. Ever found drugs placed in wrong slots or bins? Some hospital pharmacies insist on printing labels identical in color, configuration and font size for any and all prepared IV solutions. At a glance, insulin may look a lot like Oxacillin. Even some drug companies manufacture look-alike vials or use fonts so tiny each should come with its own electron microscope.

All of these points-of-potential error make pausing at critical moments all the more critical.

Granted, it takes real self-control to stop, focus and look at medications or equipment settings as if each time was our very first time. But since forcing myself to pause for each and every critical action—no matter how crazy things are around me—I no longer have those 3 AM, wide-eyed awakenings wondering whether, in haste, I’d put my career in jeopardy.

When all is said and done, none of us should ever feel we need to work faster than the speed of safe care. But when a shift does feel like it’s beginning to spin out of control, remembering to put Three Elephants between you and your patient may be just the buffer you need to keep doing safely what you do best.

Mark Stambovsky RN, MSN, is a nurse in Northampton, Massachusetts.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

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