Smart Nurse vs. Dumb Pharmacy, Round One. DING! | Life of a Nurse

**VivaLasViejas**, ASN, RN

Not only is it the day hospitals discharge frail elderly patients to the nursing homes en masse, but it seems that they do it in such a way as to maximize the inconvenience for both the new resident and the LTC staff. I mean, it can't be just a coincidence that a) new admissions arrive around 1600, when we have only half the staff that was available at noon and are getting folks ready for the dinner meal; b) they never come with a full set of orders, so the nurse has to try to pin down a physician who's already fled the office for the weekend; and c) no administrative staff are in-house to help with admissions because THEY'VE gone home for the weekend as well.

Last Friday was probably one of the five worst I've ever worked. It's common for the skilled wing to get admissions on a Friday, but my luck being what it is, I was working the LTC sections and both scheduled admissions were on my side of the building. Okay, fine, so it would be a long night, but I'm so grateful to be working at all these days that I told the DNS "oh, what the heck, I'll deal with it".

That was, of course, when everything hit the fan. First, one of my dialysis patients came home with a BP of 60/38. Then the first admit came in---a thirty-six-year-old kid in a persistent vegetative state with G-tube, catheter, trach, the whole works---and it took four of us just to get his 300 pounds into the bed. His tube-feeding set didn't work with our equipment, so I had to hunt down some different pumps and tubing sets and experiment with them to figure out which went with which. The phone rang; it was our house pharmacy with a question about a resident who'd just gotten an order for Percocet and had a supposed allergy to oxycodone. So I had to stop what I was doing and go ask the resident, who emphatically denied ever being allergic to the drug and told me to make sure her primary care doc took it off her medical record. The pharmacy would not send the Percocet without confirmation from the doctor, however, and since he was (of course) out of town till Monday, she was basically SOL.

I told the resident not to worry, that's what we had an E-kit for, and tried calling the surgeon who ordered it in the first place; he too was gone (what do MDs do---gather together in one big happy group on the golf course on Friday afternoon and get so whammered that they can't be held responsible for anything that happens between then and 0800 Monday morning?!). I had my hand on the phone, getting ready to call the pharmacy back, when they called me again. Same med, same patient, different caller. I told the woman on the other end what I'd found out, and hung up.

Second admission came in, a walkie-talkie on a 5-day hospice respite. These short-stay residents require just as much paperwork as the permanent ones, and worse, I had to write out all seven of his med sheets by hand because Medical Records had, like everyone else on the planet, gotten the heck out of Dodge while the gettin' was good. Note that I still didn't have the first guy's tube feeding stuff together yet, and as it was almost dinnertime, there were a dozen fingersticks and insulins to be done. The phone rang and I ignored it, only to hear myself being paged overhead yet again: "Marla, XYZ Pharmacy on line 1. Marla, line 1". I picked up---"Hi, this is Hmglmph from XYZ Pharmacy (anyone else ever notice that most of these folks mumble their names?). I need to ask you about Mrs. Ouchmore's new order for Percocet....."

"I still haven't heard from the doctor," I told Hmglmph, "and I can't get hold of her surgeon either. The patient is alert and oriented, she's a retired nurse and knows what she is and isn't allergic to."

"Well, we can't send the Percocet until we know for sure from the doctor that she's not allergic to it," Hmglmph said, a hint of triumph in her voice.

It was on the tip of my tongue to say that I KNEW that, but trying to locate an MD on a Friday night is about as easy as finding a goldfish in the ocean. I said, "Do what you have to.....I'll just use what's in the E-kit."

I'd no sooner gotten off the phone with Hmglmph than a fourth call came from XYZ Pharmacy. This one identified herself as "Foozitz", and yep, you guessed it: she wanted to know if I knew that Mrs. Ouchmore's profile listed an allergy to oxycodone. Just then, a crash came from the general direction of the assisted dining room and I let go of the phone and ran to see what (or who) was on the floor. Luckily, it was only a dinner tray and not a resident, so I went back to the phone---by now, I was running half an hour behind with my insulins---to finish my conversation with Foozitz.

I managed to get halfway back to my other wing before the phone rang yet again. "If that's XYZ, I'm going to scream," I said through gritted teeth to the aide who was dashing back and forth, trying to answer calls on a hall that was suddenly lit up like a Christmas tree. Sure enough, it was the FIFTH call from XYZ, from yet a fifth person, asking the same question about the same drug and the same patient.

That's when I lost my famous cool and screamed. Well, I didn't really scream, but I did make a rather loud "GRRRRRRRRRRRR!!!" sound, and snatched the phone from its cradle.

"Do you people ever talk to each other?!" I seethed. "This is the fifth time I've talked to somebody from XYZ about the same medication and the same patient. Don't you ever communicate?"

"Excuse me?" said some young-sounding girl (I think her name was something like 'Zoojaflobbets').

"You heard me. You people have called five times in the past twenty minutes about Mrs. Ouchmore and the Percocet order I faxed you this afternoon. I don't have time to deal with all these calls."

Zoojaflobbets seemed a trifle offended. "Well, sometimes we have someone from billing call about meds, sometimes it's someone from processing---we have different departments."

I couldn't believe it. "BILLING?" I yelped. "Are you serious??!" I was outraged that one or more of those calls had been made by someone who dealt only with the money end of things. "I don't give a rip about who pays for what," I went on. "I'm a nurse, I'm responsible for 40+ people, I've got admits coming in the door and a resident whose BP is in the toilet, I've got a zillion blood sugars to check, and you people keep calling and interrupting me every 3 1/2 minutes to ask me the same thing over and over. I don't have time to play around on the phone just because you all can't pull your crap together enough to fill a simple order."

I hung up a little more forcefully than usual, feeling only the slightest twinge of regret for dumping on someone because I was having a bad day. I usually go out of my way to be courteous, even to manic family members and people who try my patience like XYZ Pharmacy was doing that night. But five calls about a single, simple Percocet order?? It's bad enough that they don't group their questions about different patients and get everything straightened out in one shot, but I can understand that. Five calls about one order are four too many, IMHO.

Make it SIX calls. I'd been off the phone for a grand total of 90 seconds or so when the overhead pager announced another call for me from XYZ. This time it was the pharmacy supervisor---Zoojaflobbets had apparently run to her and complained about our little chat---and it was clear from Jwanda's tone that she believed she was dealing with a stupid country nurse who needed some "ed-ja-ma-ca-tion" on order clarifications.

Well, I may be country, but I'm not stupid, nor am I particularly fond of Portlanders who talk down to us bumpkins because they can. I listened politely for about fifteen seconds, voiced my agreement with the need to clarify orders........and then launched into a description of my day and the reasons why Jwanda's staff needed to figure out who was working on what before they called a facility. I also pointed out that pharmacists, like nurses, hold state licensure and are thus qualified to call a physician themselves if they have a question about an order; that's what our local pharmacists do, and I've worked with other LTC pharmacies that will do this as well.

Not XYZ, I found out. "Oh, we don't have the time for that," she replied.

It was tempting to ask her why they had the time to call a facility half-a-dozen times in less than 30 minutes, or just what she thought I was doing (eating bonbons? filing my nails?). But after I ever-so-gently dropped the phone---from a height of oh, about three feet---the calls stopped, and while the issue never got resolved that evening, the resident did receive her Percocet from our house narcotics supply, and had no adverse reactions whatsoever.

The next afternoon, I had to call the pharmacy for a new E-box---we'd used up all the Percocet---but the pharmacist I spoke to this time obviously had more than a few brain cells to rub together (plus some compassion for both Mrs. Ouchmore and the hardworking nurse taking care of her). Actually, "Lindy's" attitude was downright refreshing: "The patient's doing OK on the Percocet?" she asked me. "She's taken it four times now and there've been no reactions? That's good....I'll fill the order and you'll have it by tonight."

Ding-ding-ding, we have a winner!! Needless to say, I thanked Lindy profusely.......and I'm happy to report that her word was as good as her enunciation: before the noc shift came on, I had a full card of Percocet for Mrs. Ouchmore AND a refueled narc box locked in the med room.

Sometimes, as a nurse, you find yourself feeling absurdly grateful for the darnedest things. Like finding all the equipment you need in one place. Solving a sticky patient problem even the doctors and specialists couldn't puzzle out. Seeing people actually do what they say they're going to do. And NOT having to work this coming Friday night.

Smart Nurse vs. Dumb Pharmacy, Round One. DING! | Life of a Nurse

About VivaLasViejas, ASN, RN

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