Archive for May, 2010

Monitoring patients on pain medication, comment

May 26, 2010

Pain management and overdose is an interesting topic. I notice that some providers provide a patient with unlimited amounts of medication and others put their foot down and say they will limit the amount. Often in the Emergency Department, there are some people who have a nickname of “seekers”. This refers to them as patients who come to the ED and all they want is pain medication. They refuse and get angry if labwork or radiology reports are ordered, they state ” just give me a pain shot so I can go home”, are comfortable and then become Al Pacino when you walk in the room and are rolling around on the floor in pain (Literally) and then watch TV calmly when you leave the room. No one takes the time find out what is at the root of the problem, refer them to pain management or have empathy. Can we help these patients? So, you give a patient a narcotic and then they have respiratory arrest. What are we doing? We are not treating the problem. We need more education as nurses and need to learn about how to teach those patients with pain how to treat it properly. There is no absolute answer to resolve this very complicated issue. More research needs to be done on this topic.

Original Post

May 3, 2010

Title: Medication safety

It is completely devastating to make any type of medication error, even if there is no negative outcome to the patient. Although there are guidelines in place to check and recheck before giving medications, we are human and can easily overlook some steps. I agree that newborns are at risk and that there should be additional steps in place to even triple check medications given to them. Of course textbooks can tell us to check the patients name, dose, route, and allergies, but can they be missed. Yes! They can easily be missed. Often, many of the stories I have read about involve new graduate nurses still in training and student nurses. Although they are not the only ones, many nurses and varying degrees of experience can make errors. I myself made an error when I was still in training as a new nurse that completely turned my life around. There was no negative outcome, but I sure did learn the biggest lesson I could imagine. Why was the error made? I was in a hurry, didn’t follow all the steps to verify the correct medication and patient. I read the patients name on the medication and quickly hung the IV piggy back. Something popped in my head just moments later to check everything the pharmacist had typed on the bag. Quickly I turned off IV pump just in time. The medication was 4 times the needed dose for an infant! The pharmacist had made an error in the weight of the patient and gave me medication that was way more than what was needed. Thankfully this ended well. Never again am I in too much of a hurry to look at every detail of a medication.

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Medication errors have not been reduced with electronic med administration, comment

May 26, 2010

Recently we have acquired a vending machine to give us our medications… Well it is an electronic way of typing in what you need and a little drawer opens. This does not help much in reducing errors. I was beginning to think that someone in our hospital owns stock in the company that provides the machines. The doctor can order the wrong med/dose, the nurse can type in the wrong med/dose, the pharmacy can place the wrong med/dose in the drawers, nurses can misread the order on the computer if it sounds like another med. If there were some magical way to reduce errors and administer medications without killing patients and saving thousands of lives, it would be great. Actually, we as nurses are paid pretty well in order to provide the best care and to use our brains to avoid errors. Yes, we are only human, but we are humans that live in the United States where there are courts and families who want to sue. It is ultimately up to everyone in the process to evaluate orders and reduce errors.

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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Substance abuse, comment

May 26, 2010

Those who choose to abuse drugs will do so whether they are homeless, celebrities, teachers, police officers, doctors or even nurses. I agree with the previous post that we should assess our colleagues in order to provide the best and most safe care for patients. There is no excuse to be altered while at work, but it seems even more inappropriate when a mistake while at work can kill someone. I have noticed 3 people that quickly disappeared from work in the last 2 years. Later I heard that they were taking drugs from work and altered the records. They were all fired. Interesting enough, one of the nurses was seen in our facility working for a critical care transport team. My hope is she went through a rehab program and no longer abuses drugs. The only thing to do is to keep patients safe by keeping our nurses sober. The one thing that could be a potential problem and highly embarrassing is if you suspect someone for being altered and it turns out they are not and do not use or steal drugs. Many times I have had patients state “you didn’t give me my pain medication”. They say this although I show them I am putting it into their IV, but they had forgotten. Thankfully, I do not use drugs and have no interest in taking Morphine and injecting myself with it. I do know of many patients and even close friends who have fallen in the dark hole of addiction. Approaching those nurses that are abusing drugs in a positive way and offering support and rehab would be ideal. Many who abuse drugs may have deep emotional issues that are difficult to resolve.

Original Post

December 30, 2009

Title: Substance Abuse

Although there are mild cases, substance abuse can be a major problem that leads to other issues such as child abuse, elder abuse, or sexual assault. These issues are reasons that make substance abuse a serious problem. Substance abusers should put this under control as soon as possible. Alcohol treatment programs are designed to help those that want and need help be successful at this. As a nurse, assessment skills are imperative in diagnosing a substance abuse problem. Skills in the assessment of mental health cannot be forgotten, since they focus on emotional and psychological well being. A good mental health assessment could reveal the underlying problem(s) of substance abuse.

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Medical malpractice related to nosocomial MRSA infection, comment

May 26, 2010

After reading the posts regarding MRSA acquired during the hospitial stay and how this is a legal issue makes me think of one thing. Nurses need a law degree before stepping foot in a hospital. Well, that may be a little overboard. I see this everyday. Practicing medicine while keeping in mind that we can be sued. We order extra lab work, radiology, ultrasound, MRI, and swabs for MRSA so we cover all the bases and avoid going to court. I can understand the MRSA swabs that may need to be done in order to avoid a lawsuit, but we would have to swab everyone. We really don’t know if the history we are obtaining is inclusive. Is this done in other countries? Are people “sue happy”? This is a foriegn concept to some friends and family that visit the US. Maybe we can invent a body scan that will take photographs head to toe to cover wounds, swab every orifice, lower the beds to 1 foot off the ground, and make it mandatory to wear special non-slip shoes to avoid falls. Again, the above example is out of frustration that we are not only caring for patients, but always are adding new things to do in order to avoid a lawsuit. I wish it were different, but we all know it will only get worse.

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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My Close Up Experience With Alzheimer’s

May 11, 2010

During my recent management role I had the unfortunate experience of watching a close coworker and friend of mine go from a vibrant hard working nurse to someone easily rattled, couldn’t remember her patients, but unwilling to recognize what was happening to herself. After having to discipline her for medication errors she finally accepted that something was wrong and went to see a doctor. The doctor gave her a diagnosis of Alzheimer’s. It was unsafe for our patients for her to continue in the nursing role and my employer could not see a use for this dedicated employee (find/give her another position). She was only 53 years old and instead of a retirement party ends up leaving the organization in what seems like a disgrace. What a shame that there is no place in the workforce this for someone who had been such a dedicated, patient loved individual.

Original Post
November 6, 2008
Title: Protecting the Elderly
I often wonder if we do enough to protect the frail elderly. Case in point was a patient I took over from another nurse on Sunday. She was a 67 year old female Alzheimer’s patient who had been left supposedly in her grown children’s care while her caregiver husband took a long-deserved overnight fishing trip up north. Her usual state is pleasantly confused and ambulatory. Unfortunately, the daughter never went to the house, but called Mom and told her to take her pills, which apparently she did, and she did, and she did, etc. When the grown children finally arrived to the house around noon the next day, they found her nonambulatory, aphasic, and with an altered mental status. They called the ambulance. The ambulance ALS’d her by only putting in a saline lock and cardiac monitor. (No neuros, no O2) When she arrived, the MD did all the usual labs, CMP, CBC, CIP, Salicylate, Acetaminophen, UA; EKG, CXR and CT head for altered mental status. All the findings were negative except the Na and Cl were low, but CO2 was fine. When the off-going nurse gave me report, she told me the patient was restless, not following commands. She had put in a Foley and had a good output. She made the comment “But she has dementia.” Of course the side rails were up. I went in to do my assessment and introduced myself to the patient and the children. The patient was responsive only to verbal stimuli and made little eye contact and had expressive aphasia. She demonstrated tremors. She was unable to identify her daughter. I asked the family if any of that was her usual state and they said no. I initiated seizure precautions and asked the MD if he minded if I called Poison Control (which are customary nursing interventions in our ED anyway) and of course he said “go ahead.” I updated him on the assessment and he was clueless. I obtained an order for some Ativan. Poison control gave me some parameters. Since some of the meds were BuSpar and Seroquel which could both affect CNS and cardiac systems; I had been right in my gut reaction, but not that familiar with the adverse effects of Seroquel OD. We initiated NS to correct the electrolyte imbalance and she started perking up. Her husband finally arrived and she was bright, cheerful and alert! He was obviously angry and upset, and we talked a long time. I felt bad. I was upset with my co-worker for pigeon-holing my LOL just because she had dementia; she could have had a bad outcome. But should I as a mandated reporter called this in as neglect on the part of the children? After all, the husband had assumed he had left his beloved spouse in good hands for some much needed respite. He was fighting back the tears when he was talking to me.

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Medication safety

May 3, 2010

It is completely devastating to make any type of medication error, even if there is no negative outcome to the patient. Although there are guidelines in place to check and recheck before giving medications, we are human and can easily overlook some steps. I agree that newborns are at risk and that there should be additional steps in place to even triple check medications given to them. Of course textbooks can tell us to check the patients name, dose, route, and allergies, but can they be missed. Yes! They can easily be missed. Often, many of the stories I have read about involve new graduate nurses still in training and student nurses. Although they are not the only ones, many nurses and varying degrees of experience can make errors. I myself made an error when I was still in training as a new nurse that completely turned my life around. There was no negative outcome, but I sure did learn the biggest lesson I could imagine. Why was the error made? I was in a hurry, didn’t follow all the steps to verify the correct medication and patient. I read the patients name on the medication and quickly hung the IV piggy back. Something popped in my head just moments later to check everything the pharmacist had typed on the bag. Quickly I turned off IV pump just in time. The medication was 4 times the needed dose for an infant! The pharmacist had made an error in the weight of the patient and gave me medication that was way more than what was needed. Thankfully this ended well. Never again am I in too much of a hurry to look at every detail of a medication.

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