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

[UM Review RN, ASN, RN]

I've had something similar happen to me, so I changed the way I do things when I get to work: I look to make sure the patient's still breathing (even if just returned from a procedure), check the chart for the day's orders and medications, and then I go assess the patient.

All told, I probably check the charts for orders about 3 x per shift. Once, at the start of assuming care for the patient, again when I do my first charting, and the third time when I chart end-of-shift I/O's and things like that. Sometimes the oncoming nurse will peek to make sure all the orders are taken off as well.

I rarely miss new orders now with this method. Hope it helps you.

[Tweety, 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.

[KyPinkRN]

I've had something similar happen to me, so I changed the way I do things when I get to work: I look to make sure the patient's still breathing (even if just returned from a procedure), check the chart for the day's orders and medications, and then I go assess the patient.

All told, I probably check the charts for orders about 3 x per shift. Once, at the start of assuming care for the patient, again when I do my first charting, and the third time before I give report.

I rarely miss new orders now with this method. Hope it helps.

My usual routine is similar to yours... I assess everybody then before giving the 5p meds I sit down check out the chart, look at labs etc. Last night I got an admission right off the bat so I didn't have time to do it between that and another patient I had who required lots of my time. I really feel bad for not catching the order earlier in my shift. Most people on my unit do a final chart check at the end of their shift and rarely get to look at the chart unless there are new orders. This is supposed to be communicated to them by the charge nurse. It would help if the charts were actually at the bedside, like the hospital where I did my clinicals.

[UM Review RN, ASN, RN]

I wonder if a paperless system works better.

They say that this is the beauty of computer charting. Everyone can access the same chart anytime they want, no waiting.

We're going to computerized charting within a couple of years and honey, I can't wait!

[KyPinkRN]

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.

I'm not far enough out of school to forget when I did my clinicals at a hospital with a paperless system. All orders were still written on paper, then checked by a nurse, and then put in by a clerical. They then would show up on the computer at some point. There if an order was written you would know almost immediately because the charts were at the bedside and the doc had to either take the chart to the station or stand at the server and write the orders. At my hospital, our unit is so big we almost never know when the doc has come and gone, because only the flow sheet is at the bedside. There are definetly flaws in our system

[KyPinkRN]

They say that this is the beauty of computer charting. Everyone can access the same chart anytime they want, no waiting.

We're going to computerized charting within a couple of years and honey, I can't wait!

There has been talk of computer charting for us too, I'll believe it when I see it. Can't wait either.

[Dolce, 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.

Computerized order entry is a great tool. Everyone can be in the chart at the same time, so hunting down the hard chart is not an issue. All new orders appear instantly at the top of your order sheet so every time you log onto a patient's chart the most resent orders come up.

[nurseodra]

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

[Bumashes, MSN, APRN, NP]

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!

[SheriLynnRN]

At my last job I had to constantly reach over the charge nurse's shoulder to look at my charts, and annoy the heck out of her...or rely on the less than dependable unit secretary to let me know when I had a new order...A lot of orders were missed, or just not seen by the nurse in a timely manner...

The unit I work on now has a much better system. When a new order is written, the unit secretary scans it and a copy is made for the nurse. We have a magnetic bulletin board at a central area in the nurse's station where these order copies are posted on clips labeled with each nurse's name.

I really like it, because not only do I know right away when I have an order, I also get to see exactly what the doctor wrote, not just a yellow sticky note that says, "2 units PRBC's Room 702".

[Virgo_RN, BSN, RN]

We have a pretty good system in place. The MD writes the orders into the paper chart, the orders are scanned, and any drug orders go directly to pharmacy, who enters them into the electronic MAR. What drives me nuts is when the MD zips in, writes some orders, then dashes out and doesn't take the chart up front to be scanned. If I didn't see the MD there, I don't know that there are new orders, and the new orders aren't getting scanned.