Forensic Nursing Chronicles

With the start-up of EMAR (electronic medication administration record) in my facility in November 2009, we were certain of improving med administration and reducing errors. I also assumed Pharmacy would be able to deliver the new meds ordered to the floor sooner. Not so….it actually has been taking Pharmacy longer to profile the med orders. And the number of profiling errors has not reduced. It still falls on the shoulders of the harried floor nurse as the last set of eyes, to catch errors. Now I’m hoping Physician electronic orders will be the solution. Let’s just hope we get to the end point we so desire, for the patient’s sake!

Original Post
March 31, 2010
Title: 200,000 Americans killed each year in hospitals by medical errors, comment
I definitely think this is a drastic number and being on the front lines, I can see how this happens. Especially in today’s ever changing healthcare field. First, you have EMR which has completely changed our world. There have been so many changes recently that it is very hard to keep up with it all. Not only they way we chart things, but how we administer medications. Caremobile, the pt scanning device, is supposed to help catch errors. But with the Electronic charting, the charts and orders are not getting checked like they were because it is too difficult to do and navigate around. Not to mention that there are alot of issues with connectivity, timeliness of entering meds by pharmacy, etc. That by the time the med could be given, alot of unnecessary time has passed, so you may just do a work around to get the task accomplished which defeats the purpose of using Caremobile to begin with! Throw long hours, after hours "catch-up", high acuity, understaffing, and a whole slew of other issues that are dealt with daily, it is easy to see how these unfortunate things could take place. I definitely think that issues that are causing unnecessary deaths should take precedence over anything else. And fix what is the current problem before you add something else into the mix.

Original Post
March 29, 2010
Title: 200,000 Americans killed each year in hospitals by medical errors, comment
There is no simple answer to why medication errors occur. People die every year from preventable medical errors; wrong limbs are amputated, wrong organs removed, people receive the wrong medications, orders are incorrectly transcribed, medication reconciliation is often flawed, the list could go on forever. Errors are a result of human nature. While every effort is made to minimize and prevent errors, they still occur. Nursing education, annual and ongoing review of the Joint Commission National Patient Safety Goals, time outs prior to surgical procedures, are all great ways to work to prevent errors from occurring. Responses to errors should not be punitive; they are situations from which we learn. Errors result because processes fail.

Original Post
March 4, 2010
Title: “200,000 Americans Killed Each Year in Hospitals by Medical Error”
Listed in the above are common causes of medication errors: lack of sleep in caregivers, poor communication, illegible handwriting, poor staffing. These problems are encountered in all areas of patient care. There are never enough nurses, nurses have too many patients, work too many hours, and in reality are often rushed . Home medications are often not reported accurately and many physicians (who are also often rushed) write poorly. Several of the 2010 National Patient Safety Goals focus on medication administration as a result of reported medication errors. How do we change this? Change begins with education. Nurses must continue to learn about new medications and review old ones, never hesitating to consult resources if unsure about any aspect of a medication. As the last line of defense between the patient and a medication error, nurses must be dedicated to practicing the 5 Rights and the nursing process as it relates to medication administration, providing thorough assessments and evaluations even when rushed. Patients must be educated as well, and taught to ask and know about their medications, to report untoward effects and to learn about lifestyle changes which could reduce or eliminate the need for some medications. As nurses, we must continue to promote better nurse to patient ratio in all areas of care. We must exhibit professional and safe medication administration in our own practice and in mentoring new nurses just beginning their profession. The amount of reported medication errors is a sobering fact which should incite a call to all nurses and facilities to performance improvement in this area.

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With more and more people under pain management care overdose of medications is becoming more frequent. As nurses we have to be aware of the medications given very freely by pain management doctors and how to treat overdoses quickly. We see this everyday in the ER. It is unfortunate for the patients because the first thing we do is reverse the drug. This creates anxiety and pain for these patients. So education for the patients and the families is very important.

Original Post
March 21, 2006
Title: Monitoring Patients on Pain Medication

When monitoring patients on pain medications, such as morphine, dilaudid, and demerol; it is important to make sure that certain side effects do not occur. It is very important to monitor the respiratory status because decreased respiratory status is one of the main side effects that can happen from giving pain medications.

Narcan is another medication that it is important to be aware of. In one case, a patient was having apneic spells for about 30 seconds at a time and I had to administer narcan two times within a half an hour. I had my doubts about narcan through my readings, but seeing it personally really made me a believer. A simple medication can reverse respiratory depression and help the patient have a normal respiratory status.

It is also important to educate patients about pain management at home. When patients are taking pain medications at home, there is not a nurse or a physician there that can help if something goes wrong.

The main area that needs to be covered before discharge is side effects that need to be reported and the right dosage amounts that can be taken at certain times. Make sure that the patient is very knowledgeable about the medications they are taking and that they know when to call a physician or nurse when something is not right.

Pain medications are a wonderful thing, but can have their side effects that are not so good. However, by keeping a good eye on your patients and making sure that their vital signs are stable you will help the patient have a quicker and less painful hospital stay. Also, make sure that patients know what medications they are taking and what side effects may happen as a result of the medications before leaving the hospital.

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Although this entry was posted in January, 2007, nosocomial infection is still a political and safety topic in today’s health care. Reduction of health care associated infection is one of the 2010 National Patient Safety Goals, and MRSA is still a great concern in all areas of health care. It is present in all avenues of society and especially in close living conditions such as prisons, nursing homes and group homes. Most health care workers have been exposed to active MRSA infections and many are colonized as well as patients. According to the CDC "Campaign to Prevent Antimicrobial Resistance" (2002), health care practitioners are to use antibacterials wisely; yet many patients are still being treated for specimen contamination, and colonization as well as in the absence of a positive culture and for extended periods of time. Vancomycin is the drug of choice for active MRSA, and though it used to be a "last resort" drug, it is now frequently given. This is a potentially toxic drug with some serious side effects. Given IV it can cause a systemic reaction of hypotension and shock-like state with flushing (red man syndrome) and it is irritating to the vein, frequently causing thrombophlebitis. Ototoxicity can occur and is more probable with high doses and increased duration of therapy. Vancomycin can be nephrotoxic and should be used with caution in renal impaired. As stated in the above CDC publication, practitioners must "know when to say no to vanco." When it is ordered, nurses must be aware of meticulous infection control, using appropriate personal protection and educating patients and families on MRSA and infection transmission. IV sites must be monitored and changed frequently, and vancomycin infused at an appropriate rate. The patient must be monitored for side effects and toxicity and vancomycin peaks and troughs should be monitored. As nurses, we are called upon not only to help our patient heal, but to do our part in preventing infection transmission, not only in the hospital, but in all aspects of care.

Original Post
January 16, 2007
Title: Medical Malpractice Related to Nosocomial MRSA Infections

The media and government have educated the public in the “super bugs” some patients become infected with in the hospital environment. The most widely known “super bug” is methicillin resistant staphylococcus aureus (MRSA). In June 2006 there was a case brought to court regarding the death of patient who had been in the hospital for a knee joint replacement. Since the patient had not been screened for MRSA prior to hospitalization it could not be proved if he picked up the MRSA during the hospital stay. With the documented community acquired MRSA he could have had the bacteria dormant in his body when he was admitted for the planned surgery. The doctor and hospital were not found negligent in this case.

Many hospitals are fearful of similar lawsuits based on nosocomial infections. Some hospitals are now culturing high-risk patients prior to hospital admission to determine if they are colonized. There is now a nasal swab test that has a turn around time of two hours to identify MRSA. Certainly this can be helpful so that colonized patients coming in for elective procedures can have this treated and also be isolated from non-colonized patients. Patients that test positive for MRSA can be cohorted with like patients or put in private rooms. There are multiple hospitals in Europe starting to follow this intervention with positive outcomes in their nosocomial rates.

It would seem to me the hospital administrators would prefer paying for the MRSA culture versus facing the potential of law suits from patients who develop nosocomial MRSA infections while inpatient. If I had a family member going to the hospital I would much prefer they be tested for MRSA prior to a surgery as “knowledge is power” Having the knowledge of colonized MRSA prior to surgical intervention can allow for adjustments that lead to positive outcomes for the hospital, surgeon and patient. I can visualize hospitals even being forced to do it to allow them better leverage in the court system by being able to say, “this person was colonized with MRSA” prior to hospital admission. From the epidemiology stand point it would also allow the opportunity to keep the more virulent strain of community MRSA from entering the hospital environment.

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