There's a Mousetrap In My Med Cart - page 6
As some classmates in our RN nursing program gathered around in a small group this morning, I sided up and listened to a story that quickly carried me back in time when I was a newly licensed practical nurse (LPN) just learning... Read More
- 2Apr 14, '09 by expltcrnmy gut reactions to your post: 1) agree with person who stated your true calling could be writing (which i believe is mine as well, but life happens, 2) my hair stood up and my stomach was churning in response to the unpleasant familiarity of the situation you explained – although long past, once one experiences what you have described, the nervous system does not forget! i have been a nurse for close to 20 years of which 17 are in ltc, short-term sub-acute, hospital based snfs as a don, nurse manager, nurse consultant, dsd, qi director, and all of the other hats possible, including charge nurse, med nurse, treatment nurse, iv nurse, etc. etc.
what a great way to bring to light issues still faced by many nurses in the ltc and elder care arena (and some acute care units as well) too many patients, too many meds, patients getting sicker, and some unrealistic expectations, not enough nurses, not enough help, not enough tools and time to succeed! i have continued to do what i do because i know i make a difference. "never underestimate the difference you can make,” quint studer.
my current favorite thing to say is, “i believe there are enough of us who care about what we do as healthcare providers, who truly believe that by teaming together we can make a difference in the lives of the people we touch, such that we can work through the challenges we face today and influence, coach and mentor those under our wing.” however, in order to impact systems and make some practical changes, here is what i would suggest if you have not already tried these steps (these are directed to those especially new to ltc regulations, etc., or those who are simply looking to vent, as well as those looking for some practical suggestions).
· follow your chain of command – ask to meet with your supervisor or don, go as a team if you feel there is more accomplished with more people involved. you may say, “what if the problem is the don? or you have already approached the don and nothing changed?” ask for another meeting again, but in this meeting, present your concerns in this suggested format:
state “we have discussed these concerns before, but we feel there has been no change” (be specific – avoid generalizations). proceed to say, “we would like to follow our chain of command to resolve these concerns.” (be prepared to provide suggestions/solutions to the concerns you bring forward). then state, we are documenting this meeting and we would like to either formulate a plan with you with a goal date, or meet with us again on a future date to present us with workable solutions”. set your goals and timelines. then be clear that since you are following your chain of command, that if certain goals are not met, or you feel you are not being heard, you will go up the chain of command following usually facility protocol. continue to document with follow-up meetings and refer back to your notes as needed.
an investigative body (be it regulatory, quality, corporate, legal) will usually ask these things when something happens, “did you follow your chain of command? if not, why?” by failing to take advantage of the chain of command process, you may be placing yourself in a disadvantageous position, and may even be treated as part of the problem, whatever it may be.
this above process only addresses things not considered to be emergent, urgent, or a threat to the safety of the patient. remember, patient’s safety comes first.
· when you are working on solutions as a team, involve as many people as possible – develop some quality action teams within the workgroups (2-4 people mini-committees) to be champions (leaders of the solution)
· consider the split time for med passes as another writer suggested. increased staffing is not always an option especially with the nursing shortage. some facilities i worked in split the big halls into 2 for physician order writing/times actually in mars based on room#s (am meds are 0800 for 1 group and the rest of the med pass times are adjusted to this time schedule, and the other group starts at 0900)
· work with your pharmacist and physicians ideally upon admission (or within 72 hours) to review duplicate therapies, combining some bids into single dosing when it doesn’t impact the clinical effect, moving non-significant meds to noon for the daily meds (such as multivitamins), studying the necessity of each single medication being given. we are not doctors and cannot prescribe, add or d/c medications. however, a consulting pharmacist usually has tools that nurses can use to help streamline meds and reduce unnecessary medications. call your pharmacist for those!
· consider putting your insulins/hypgolycemics on a separate medication sheet on a different color (we have used pink – for diabetes in some facilities). so, at the beginning of your pass, you can quickly leaf through the pink sheets and id your insulins prior to the beginning of the rest of the routine med pass.
· we all know we have residents who have highly individualized needs/requests – for the known ones, one of the tricks we used was a medication pass instruction page, or an alert page in front of each resident’s medication profile, so in case someone forgot to give you specific instructions or some tricks of the trade on specific residents/meds/etc. – you can actually look at it as you are flipping to the medication sheets
· gather the assistance of team members to keep medication passes as uninterrupted as possible – easier said than done at times. but go back to following the chain of command, one of the things you will have to ask for is administrative support of reduced interruptions, additional assistance from non-technical staff (presence) while you are conducting your heavier medication pass (unless urgent, try to have them take messages).
· institute bedside rounding – will be tough at first especially with bigger facilities, but will pay off in the long run. if you have too many patients (this is subjective since levels of care differ, and acuity differs), at least do the bedside hand-off on your priority patients (new admissions, change of condition, post fall), so as you are reporting off, you are eyeballing the patient.
· engage your don and administrative team to problem solve with you, what systems need to be put in place. the medication pass is not all that you do. however, it does take up more than half of your day’s work, so any other duties and responsibilities will appear minor when you have a horrible and never-ending medication pass.
· if some of the tactics do not work right away, ask for the manager team to shadow a licensed nurse for the entire shift strictly for observation (an assist of course) of how your day goes.
i hope and pray that through venues such as this, we can continue to grow as a profession, nurture each other, and prepare each other to deal with the challenges we are yet to face in the future. more power to you all!
- 1Apr 22, '09 by 99percentangelDear EXPLTCRN
Thanks so much for taking time to post such an enlightening article in response to my story. I'm printing it out for when I'm the "Manager" RN and can put this to very good use where it will make a difference.
Keep up the good work - and writing!
~Linda aka 99percentangel
- 0May 14, '09 by pilya00i love your article. i can relate to it. i'm a new night shift nurse & med pass is a struggle for me. i am responsible for 50 patients, half of them gets either a pill or glucose scan or both during the morning. it was my first day on the job and it took me more than 2 hours to do the med pass, i started 4.30am. one resident needed monitoring & i had a hard time to some GTubes. Some residents gets crushed pill/whole pill in apple sauce or pudding. And one resident would not take the pill because i am nice to her room mate while giving meds. to make the story short i had so many adjustments to make while doing the med pass. and the incoming nurse with a irritable look from her face told the other nurse that i should not be in charge during the shift, that i should start somewhere else because i am terrible. that she can not take it because i am so late. i didn't do my report with them yet at 7.15 because i am still struggling with the med pass. i really wanna cry but i need to move on to be finished. my hands are shaking because of the pressure that i feel from her but i need to make sure that i do my job with no error. i don't know if she intends to make it loud so i can hear it or its just her voice. i also hear her saying " oh no, she's only in room X." then ask me, "how many residents do you still need to do?" that adds up to the pressure that i want to let go. i really wanna cry that moment. i just told myself i need to be strong. until now i can't forget the look from her face & what she said. i just pray that my situation will get better. Thanks to your article. Now i know im not alone.
- 0May 14, '09 by dina77It brings back memories of when I used to give medicines to 24 patients. It's not an easy job with patients needing mouthwashes after certain inhalers, tablets needing crushing etc etc. It is hard work with all the problems you come across too, e.g. breaking off to answer the phone, taking desperate patients to the toilet, the list goes on.
Where I work now patients have their own individual medicine chest, so you just give the mediction to the patients you are looking after in that shift. It is also easier because you are not looking through piles of tablets for what you want.
In my 30 odd years of nursing I haven't seen many changes that actually make our life easier as the amount of paper work to do now is phenominal, but this is actually one change for the better!
- 0May 20, '09 by zunsyne"Signed under duress. Med passes done outside the open window causes included a patient who had fallen and who required fall protocol procedures as well as the requirement to care for the Charge Nurse who exhibited symptoms of cardiac distress. No assistance was given even to me even though I notified heard nurse of the impending problem."
Very original, I work PT at an AL facility and in addition to passing meds, I have to answer the phone from 7-9 am, which is not an easy task and a task that I've spoken to mgmt about it not being safe. Additionally, i've got residents who you have to go searching for once they've left dining room, or residents who decide to get dressed at 6 am and just go for a walk, then there's the odd resident who falls and needs assistance immediately. With all the distraction going on there's no way 34 residents can all get their meds within this timed window.
- 0Jul 1, '12 by Collegegeezer12I love this story, it houses so many memories for me. The gauntlets never cease, you only become more used to them as you learn to adapt and come up with a workable compliant med-pass. I especially enjoyed the detail expressed on how much has to be done in so little time, and can only add that there is a social aspect thrown in with the blood pressures, neuro-checks, residual checks, etc. The very reason I start each day with prayer. Be blessed!