Archive for September, 2007

Medication Errors comment from June 6, 2007 posting

September 12, 2007

Unless my patient is unconscious or not able to understand due to age or illness, I can’t imagine not giving some type of brief explanation or at the very least, “Hi Mr. Smith, how are you feeling? It’s 10am and time for your Lasix” and not saying “here, take this”. Communication by the whole health care team is so integral to positive patient outcomes – have we become so task oriented that common courtesy and just plain politeness doesn’t matter? I sure hope not.

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Investigative Nature of the Job

September 12, 2007

Nursing Pharmacology and Forensic Nursing are similar in that both must do investigative work.

During the premedication assessments and the evaluations, nurses must delve deeply into the patient’s background and history to obtain information relevant to the symptoms the patient is presenting with. Nurses must be very aware of non-verbal indictors that will aid in making the correct diagnosis. Nurses must also be aware that patients don’t always offer accurate/truthful information and need to err on the side of caution when factors such as street drug use or excessive alcohol intake could greatly increase the risk factors of some drugs.

Forensic Nursing does intensive investigating of crimes such as rape and abuse that will result in legal ramifications. Forensic nurses use their healthcare background and advanced training in forensics to help solve crimes and to assist the victims of these crimes.

Both nursing professions need to develop superior people skills and learn how to foster trust in the patients/victims that they deal with.

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No Harm No Foul: If Nobody Gets Hurt, Is it an Incident?

September 11, 2007

In the book HEALTH PROMOTION THROUGHOUT THE LIFE SPAN, by Carole Edelman and Carol Mandle. Mosby, Inc. Chapter 3 discusses medical errors and refers to the 1999 Institute of Medicine (IOM) research study, To Err is Human: Building a Safer Health System. I had also read an article in OUTCOMES MANAGEMENT titled An Innovative Method of Collecting Adverse Event Data and was very intrigued by both of the articles. So, I conducted my own study at the small, rural community hospital that I am employed. I had noticed that only a small percentage of medical errors were being filed as incident reports and I wanted to know WHY. I made up an Anonymous Adverse Event Survey Questionnaire. For 10 days, one was given to every nurse at the beginning of each shift and to be returned in a plain brown envelope at the end of each shift to keep it anonymous. Over the years, I had heard a lot of grumbling that “Management doesn’t do anything with the incident reports anyway” so I had included that in the 11 reasons for not filing an incident report. The results were amazing. Of the 281 surveys handed out 209 were returned (74%). Of the 209 returned, 130 (62%) reported no adverse events and 79 (38%) reported adverse events. However, of 79 that reported adverse events, only 17 (22%) filed incident reports. That leaves 62 (78%) that did not file incident reports. The most commonly reported reason 21, answered no harm sustained (34%). Nurses that did not think it was an incident 14 (23%). Seven nurses (11%) thought an incident report was not necessary because they informed the nurse involved. Six (10%) did not think that the incident report is used by management as a tool for improvement. Four, (6%) did not want to take the time to file an incident report. Four, (6%) believed it was a waste of time because nothing is done with the reports. Three (5%) answered none of the above and wrote an explanation. Two (3%) feared retaliation from the nurse involved. One (2%) did not know how to use the computer incident form. Zero (0%) feared getting too many incident reports in their file. I added the first 2 reasons together, no harm sustained and did not think it was an incident to equal (57%). That is (57%) did not think they were incidents to be reported, yet according to the returned surveys 14 were medication errors and 4 were patient falls. So, the major barrier to make our healthcare system safer continues to be the question of what constitutes an error, adverse event and incident. (The complete survey report available upon request.)

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Measures to protect patient information

September 11, 2007

1- Administrative safeguards:
a. Implementing practices to reduce identified risks;
b. Instituting a system to regularly review records of information system activity, such as
i. audit logs,
ii. access reports,
iii. and security incident tracking reports;
c. Developing a policy to sanction staff members who violate the offices security procedures;
d. Designating one staff person to be the Security Officer (similar to the designation of a Privacy Office as required by the HIPAA Privacy Rule);
e. Establishing who on staff has appropriate need to access patient records, and who does not;
f. Establishing and providing a security-training program for office staff.

2- Physical safeguards:
a. Hospital departments should be kept secure from intruders—with locks, alarm systems and other security devices and systems –the department is not open for business;
b. When the department is open for business, unattended areas are still kept secure with locks and other devices if possible, but at least closed doors;
c. Physical access to filing cabinets, computers and printers, photocopiers, fax machines and any other areas or equipment where patient information may be present should be controlled and monitored;
d. All workers should wear the organization identification badges at all times;
e. Patients and visitors should be appropriately escorted to ensure that they do not access restricted areas, and unidentified persons in restricted areas are (politely) challenged for identification;
f. When a person no longer works at the organization, keys and identification badge should be returned, alarm codes are changed, and computer access should be removed within one day.

3- Technical safeguards:
a. Computer passwords should be kept secure, and changed regularly;
b. Computer access tokens (such as key cards or USB keys), if used, should also be kept secure;
c. Computer screens should not be in plain view, where anyone other than staff can easily see them;
d. Users should log in to computer systems or terminals only with their own user ID, password or token; these only may be shared in extraordinary situations.
e. If there is no password-protected screensaver on the computer, log off when a computer system or terminal is unattended, even if it is only for a short time.
f. Computer systems should be used only for work-related functions (“playing” can provide a way in for viruses and other computer bugs);
g. Portable computing devices (laptops, PDAs) should be kept secure by remaining in the department or by password protection.
h. When a person no longer works in the organization, his/her computer use IDs and passwords should be immediately deleted, and any access tokens should be returned.
i. Use of computer-based patient information should be limited to the minimum necessary to get the job done. (Minimal security rule)
j. PHI (protected health information) should be stored on the secure servers in secure zone.

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Medication Errors-A comment

September 10, 2007

Medication errors continue to be a problem in healthcare causing undue harm to patients. My experience as a clinical leader on my unit is that the errors are a result of a poor system, frequent interruptions, and staffing issues. I am hopeful that the Physician order entry and eMAR…coming soon, are helpful in reducing our error rate and making the process more efficient. In review of errors we make, initial errors are a result of incorrectly profiled medications from Pharmacy. If not caught by the nurse, the error may reach the bedside. Others are in the delivery process where a Pyxis machine (a computerized medication station that links the patients profiled medication to a tower holding the medications) may direct the nurse to remove two to make the required dose and he or she may remove one. In review of the incident reports, it was determined that errors were linked to frequent interruptions during the delivery of medications. Nurses need to be able concentrate during this task but phone calls, pt requests, post-op patients arriving, needs of coworkers, chatter while in line at the Pyxis machine, family members needing attention all contribute to the fragment process. Our Pharmacy recently had to close at night due to a shortage of Pharmacists. The result from this was adding more towers and loading more drugs into the Pyxis machines and providing more override capability to nurses. Unfortunately at this time, space for Pyxis machines is limited so one of two machines is located in a hallway next to another open unit and in open view of patient rooms and hallway traffic. We are currently in the process of designing a booth-type barrier at the machine and implementing a system of rules during medication delivery. Wondering how the implementation of the computerized system will help. The interruptions and needs of patients will be the same. Human error in ordering and transcription will remain the same and the space issue on our unit will go unchanged.

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Organ Donation

September 10, 2007

Yes, in Ohio we are asked that question of “do you want to donate your organs”. This does seem rather cold and heartless. There is no follow up to that question if it is answered yes. There is no counseling. You have people at the BMV/DMV asking you. Not medical/forensic personnel who know what they are talking about. I could have said yes at the age of twenty and now I’m forty and my family might not know anything about that decision I made a long time ago. I had a baby on my unit that was terminal and on life support and it took the family weeks to come to a decision. The “loop” team was involved and talking with the family. But they did seem a little “pushy” about getting those organs. We just instituted a new policy at my hospital stating that if one went to the OR to harvest organs then the ethics committee would have to be on standby and come in as a “double check” for the family. Just to make sure they understand what they are deciding upon. If one says yes to organ donation at the BMV/DMV there should be information given/sent by forensic nurses/team so the person saying yes has a more informed consent.

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SIDS

September 7, 2007

I work with infants and we have had a few cases of SIDS come up in the last few years. When we have a family in the unit who has had a child die from SIDS we do take precautions and send them home on an apnea monitor. Studies say there is no genetic link but who knows. We don’t really know why SIDS happens. If you had a SIDS case I think the forensic nurse should look at more factors than what was listed in the article. It is hard to determine what happened. One should be looking at family, environment, second hand smoke, nutritional status of the infant, growth and development of the infant and not just the autopsy finding. With the new newborn screens that have come out in some states, hopeful some of the screens will pick up if it is a metabolic/genetic disorder prior to the event happening. Maybe some of these different labs should be added in addition to the autopsy. So maybe it could be genetic disorder.

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Forensic Nursing, Pharmacology and the Forensic Pharmacist

September 6, 2007

Forensic Pharmacists deals with the application of medication sciences to legal issues. They have a specialized knowledge concerning the practice of pharmacy and are frequently used when a deceased person’s outcome is not expected. This can cause a basis for legal action, which requires the expertise of a Forensic Pharmacist to assist in legal issues pertaining to the pharmacological scope of an investigation.

For example, in the event of a death investigation, Forensic Pharmacists are able to assess a person’s medication history in order to review what medications the deceased was using and to distinguish whether their medications used alone or mixed with others were cause of their death. If alcohol had been ingested, a Forensic Pharmacist would be able to determine whether the amount of alcohol interfered with the deceased medications and may have caused an additive effect to the alcohol or medication. They are also an asset in interpreting drug levels for investigations.

Some issues concerning Forensic Pharmacists as written by Peter D. Anderson, Pharm.D., R.Ph., DABFE, FASCP, FACFE are prescription forgery; screening and testing for drugs of abuse; medication errors; adverse drug reactions; drug impaired driving; drug induced violence; and poisoning.

The Forensic Nurse and the Forensic Pharmacist are valuable assets in legal investigation. Because of their expertise in their medical profession, they are able to join forces in order to make assessments, diagnoses, evaluations and outcomes pertaining to a particular investigation. Through assessments and collecting pharmacological data, they are able to screen and test for alcohol and drug usage via blood samples; check hospital records for medication errors; check to see if the medication the person was using was a legal substance regulated by the FDA; and whether or not adverse reactions when mixing medications were a cause for a person’s death.

Forensic Pharmacists are involved in more than legal investigations. They can be found serving as an officer on a drug testing crew for the Olympics; serving as a Consumer Safety Officer for the FDA; employed as an investigator or special agent for the DEA, FBI, state Health Department, Narcotic Agency or Board of Pharmacy. They also work as criminalists for police departments; provide pharmaceutical services at prisons and serve as toxicologists for medical examiner’s offices.

A Forensic Pharmacist has a broad range of avenues to perform their area of expertise. They are definitely an asset in investigations and legal issues.

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Anthrax

September 5, 2007

I often wonder if Anthrax has not already been released. In small amounts does it cause less severe symptoms. If you know you have been exposed, what antibiotic treats it? What is actually in the vaccine, if the vaccine is not intended for humans? How much would have to be released and how is it released? What does it look like?

A full head to toe nursing assessment would have to be done. Anthrax seems to mimic so many different diseases. The focus would be on skin, GI, and Respiratory systems. It would be difficult to figure out if you did not know that there was a definite Anthrax exposure. The forensic nurse would have to have a calm and respectful approach to the victim and the family. But, in order to figure out the puzzle the forensic nurse would have to ask the questions. One would not want to induce panic either, from the family or the media.

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NCLEX-RN(r) Examination, comment

September 5, 2007

RE: NCLEX-RN(r) Examination; posted August 20, 2007

Does the NCLEX-RN Exam contain questions about forensic nursing?

Answer: The NCLEX-RN(r) exam does not contain questions specific to Forensic Nursing. Some of the content for the NCLEX-RN(r) is utilized within Forensic Nursing. Within this blog, see more about the NCLEX-RN(r) Review under the heading FORENSIC NURSING RESOURCES.

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