Missed orders!

[KyPinkRN]

Yesterday at work... I have a patient who is fairly stable, arriving to the floor after just getting a picc line placed about the same time that I came to work at 3pm. Fast forward to 11pm when I am finally getting to sit down and do some charting... I am looking up labs on the computer to update my report sheet and I see that this guy has a Hgb of 7.8. So I get the chart to see if he has had a transfusion or any plans for one... and there it was, an order written at about 11 am that morning to transfuse two units. I was told nothing of this transfusion in my report, and I don't think the nurse before me knew anything about it because she didn't mention it... the patient was off the floor for the end of her shift so she couldn't do her chart check. My concern is that when an order that important comes across the desk of the charge nurse (who is also our asst. nurse manager) the nurse caring for that patient should immediately be notified. Not being found by the next person 12 hours later!:angryfire

[Becca608]

the system we use has only the doctors entering orders too.

I decided my first clinical rotation in a hospital that MDs should be computer charting. I've got better things to do than to find five other busy people to interpret what is often a series of straight lines with a couple of loops. Is there a specific class they take in med school to learn how to write that badly?

[MikeyJ, RN]

The hospital I work at does paper charting and it is actually fairly efficient. During shift change, we do something called "shift audit" and that means both nurses have to look at any orders written that day together and sign off on them. This really helps with nurses missing orders.

However, in regards to the OP's problem, I do agree that the previous day nurse should have definitely implemented the order... but the hospital I work at would hold you just as responsible. The nurses coming on to a new shift has the responsibility to look at orders for that day (in my opinion anyway).

[Dolce, RN]

I love the way my hospital does things. We have a unit coordinator, and one of her many tasks is to enter new orders in the computer (we are responsible for going behind her to be sure she transcribed it correctly). Then, she flags the chart and puts it in a special rack for charts with new orders. Also, she scans the order to pharmacy, if needed, and the patient's name gets highlighted on the computer so you know there's a new order. It's wonderful!

The problem with this system is that it is still a multi-step process. The doc has to write out the order on paper (wasting trees) and then the unit coordinator has to enter it into the computer. If she misreads the doc's handwriting there is an error. Then the nurse has to insure that the transcription was correct. I have found that if you have 5 nurses you can have 5 opinions about what the handwriting actually says--only to call the doc to clarify and find that they meant something entirely different. We need to be having the doctors getting on the computer charting system themselves and entering their own orders. That way whatever they wrote will be sent directly to pharmacy, dietary, therapy, nursing, etc. I have been amazed at the compliance of the doctors in a teaching hospital that I work for through my agency. Since that is their only method of entering orders they have to comply. There are no paper order sheets. A couple of times I have had to help a resident enter orders but for the most part they learned the system and use it. If only every hospital worked like this!!

[Nightcrawler, BSN, RN]

This is why I like the idea of night shift doing a thorough 24 review of all orders.

I've noticed during the day sometimes I've picked up a chart out of the rack only to find orders. It's frustrating, but when you have two or three docs per patient, social services, case management, pt, ot, dietary, students, etc. picking up the chart, these things sometimes happen. Or sometimes an order is written and it takes six hours to reach the nurse.

I wonder if a paperless system works better.

Our Unit does checks at night that go all the way back to admission for medications. Some grumble and say that a 24 hour check should never go back for longer than 24 hours but last week we had a patient that had been on the floor for 2 days and treated as a med surg overflow when in fact he had telemetry orders. This patient had never been placed on tele, and the nurse before hadn't caught the missed order. If I had done a check of just the last 24 hours, the missed order may have never been caught

[Transplant-BSNTx]

The hospital I work at does paper charting and it is actually fairly efficient. During shift change, we do something called "shift audit" and that means both nurses have to look at any orders written that day together and sign off on them. This really helps with nurses missing orders.

We also utlize something like this in my hospital. Both nurses, incoming and outgoing must check their patient's charts at shift change and go through each order to make sure it was implemented. Then both nurses sign after the last order entry, holding both nursing accountable.

We have a chart flagging system. When the NP or MD writes an order, they turn the chart flag to red for "stat" or yellow for "routine" orders. After the unit secretary enters the orders in the PC/transcribes them onto the MARS the chart is flagged green for the RN to check the chart. After the RN checks the chart and signs off on the orders, the chart flag is returned to black. It's actually a very effective system and we usually never have a problem with a NP or MD flagging the chart appropriately after they write an order.

Also, if medications are ordered, or labs are ordered, the unit secretary automatically faxes a copy to pharmacy and/or enters the order into the laboratory system.

[RosesrReder, BSN, MSN, RN]

Our Unit does checks at night that go all the way back to admission for medications. Some grumble and say that a 24 hour check should never go back for longer than 24 hours but last week we had a patient that had been on the floor for 2 days and treated as a med surg overflow when in fact he had telemetry orders. This patient had never been placed on tele, and the nurse before hadn't caught the missed order. If I had done a check of just the last 24 hours, the missed order may have never been caught

We (night shift) do 24 hr chart checks; however, it's been proved not that great as we catch way too many med errors/mistakes from day shift. We are advocating for 12 hr chart checks.

[StrwbryblndRN]

I am happy with our system which sounds like NancyNurse08. I would just like to see docs put in their own orders. It would take alot of guess work out of what they want done. Can't read their handwriting and it takes

2-3 people to decipher and sometimes we still can't get it.

(one time I had to ask a doc what his assoc wrote. It took him a few "ums" to get it too)

[suanna]

At our hospital we have to sign the order sheet "EOS (end of shift) review" with the on comming and off going nurse with change of shift hand off. That way there is no excuse for missed orders.

[litbitblack, ASN, RN]

We do 12 hr chart checks and that helps tons. I have had to pass blood transfusions on to the next shift unfortunately because we got a transfer that had an order at 730 am to tranfuse 2 units. They had only done one when he go to the floor at the same time as a direct admit. Well this one had a turp and was clotting galore. I spent most of my time (as charge) in there irrigating his foley becasue it wouldn't work. In addition we didn't have a unit rep and everyone else doesn't do the desk and they have their own pts so I also had to get new orders on the new pt, assess him, and stuff because his nurse was the same as the one with a transfusion and she was getting frazzled having never had to deal with that before. my manager had to work the floor that nite as charge and I heard that she said she was disgusted to even be a part of that floor because of the blood not being started. So where is my priority. A clotted cbi that won't keep running and a new direct admit or getting blood started.

[GeminiTwinRN, BSN]

We have CPOE (comp. physician order entry) and I love it. Not only can the physician enter orders, but if need be we can place verbal orders on the computer much the same as the old way of writing them out as vo's.

We have just now gone completely paperless on discharge orders, too. The physician must select all previously reconciled home meds/meds ordered inpatient, place all future f/u appts in the orders, and add all activity/diet/work/etc orders by simply checking boxes. It's soooo simple, we as RN's must make sure that ALL home meds are in the computer or else all will fail. If the home meds are not reconciled, the person cannot be discharged, period. I'm sure there will be some crusty insistent MD's who will balk at these changes, but overall, it is so much better than trying to make out that handwriting that previously couldn't be trusted without clarification on a med, that went on to write illegible discharge instructions.

I'm not sure of what system our hospital is on, I'd guess it's meditech or something similar. Even all the rehab/PT/OT/Speech notes and things are computerized now.

It was a tough transition originally for me to go from paper to this, but now when I get pulled to a paper floor, it about kills me.

Oh, and to answer the OP problem of missed orders, all "new" and orders that have not been "noted" by an RN are in blue. Once noted, they turn black. If it's something written on your shift but not due til the next, we leave it blue so the next RN sees it and has to note and implement the order, ie.. labs that are due at 0500 the next morning, or a head CT c and s contrast at 0500, that sort of thing.

Orders will still get missed from time to time, it's bound to happen. Much much less than when we were paper though, I'm sure of it.

We do 12 hour chart checks in our assessments on the computer. We simply do them under "shift summary" in the focus note section. Very simple.

[ASSEDO]

Missing an order is bad. However, that doesn't hold a candle to poor physician handwriting. The hospital is responsible for appropriate doucmentation as outlined in the the Code Of Federal Reg

[northshore08]

Docs just started entering orders within the last few weeks....It's a challenge for them, but I think it's much better. We are using Epic and I love it!