As any nurse knows, a state survey or JCAHO inspection tends to bring out the worst in a facility. And as any nurse-manager knows, the survey team usually uncovers mistakes that we never even dreamed our departments were capable of---stupid, careless errors committed by staff who are too busy, too overwhelmed, or yes, too lazy to use the safe medication systems in place.
Many years and many surveys/inspections after my very first as a manager---the one that got me fired for the first and only time in my career---I've come to be rather protective of my med room. When we bring on new med techs, the first thing I hand them is my dog-eared nursing drug reference and teach them to look up each and every medication they don't know, BEFORE they give it. But somehow, when State is around, we discover things like this little gem, written in the MAR by hand (and without a start date or initials to boot):
"Lamidal 50 mg tab
1 PO QD for urinary tract infection".
First question: What the deuce is Lamidal? I'll be the first to admit that with hundreds of new drugs coming out every year, I'm always having to look things up (that's why my yearly drug book usually falls apart before the next edition arrives). But when I went to look up this particular med, I couldn't find it......anywhere.
Second question: The resident's UTI had cleared up two months ago,and a follow-up UA had been negative. So why was she still taking a medicine for UTI? I realize that some patients must take prophylactic antibiotics for chronic UTIs, but this lady wasn't one of them.
So I went to look at the original order, which was written in the typical doctor's handwriting. But it was clear as day that the order read Lamictal, 50 mg PO QD, which obviously is NOT for a bladder infection......and the mistake had continued from month to month. Needless to say, it made us look pretty foolish in front of the surveyors.
Here are a few other issues that raise their ugly little heads during med transcription and administration that not only make even a good facility look really stupid, but endanger the patients our systems are designed to protect.
Failing to actually read the order
You'd think it would be simple to transcribe an order like "Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." But if you're not paying attention, you might see only the "2 mg tab" on M-W-F, and thus underdose your patient. It's a lot of fun to explain this to the anticoagulation clinic when they're on the phone demanding to know how the patient's INR could be 1.1 when he's supposedly getting 7.5 mg of warfarin 4 days a week with 10 mg on the other three....
Giving an unfamiliar drug without knowing what it is, what it does, and what to watch for
How anyone can do this with a clear conscience is beyond me, if for no other reason than CYA. After all, it's your rear that's going to be barbecued when a patient is harmed and you have to testify in a court of law that you didn't know what side effects to monitor for because you never bothered to look up the med. And with the Internet available practically everywhere, this information is literally only a mouse-click away. There are NO excuses!
Allowing distractions when pouring medications
At one facility where I worked some years ago, I had some trust issues with the staff, so I came in unexpectedly at dinnertime on a weekend 3-11 shift to see what was happening. Right out of the starting gate, I saw that two of the CNAs were in the med room, which was against the rules, and they were gossiping with the med tech while she was popping pills. Not once did I see the tech even glance at the MAR or the pill cards while she was doing it. And when I compared the med cards against the MAR, I found that she'd pulled the 2100s instead of the 1700s.
Neglecting to document medications in all the right places
During our recent survey, we narrowly escaped a 'harm' tag for sloppy narcotics documentation on one particular resident who uses a lot of PRN pain meds. (Which should've triggered a pain assessment on my part, IF someone had notified me and/or IF I'd been auditing the MARs as often as I should.) The med would be signed out in the narcotics book and on the front of the MAR, but not on the back; or, it would be signed out in the narcotics book and documented on back of the MAR but not on the front; or, it would be signed out in the narcotics book and not accounted for on either the back OR the front of the MAR. Nine med techs almost had to go to OccMed and pee in a cup, while three managers holed up in the administrator's office for two solid days putting all the puzzle pieces together to prove that there was no narcotics diversion going on.
Administering meds on auto-pilot
About a year ago, I was consulting in one of our sister facilities about their survey results, which made ours look like a walk in the park. At lunchtime, the corporate nurse and I watched in amazement as their med tech passed meds in the dining room, which included the administration of several insulin injections.....without benefit of the diabetic MARS in front of her as she dialed up each insulin pen. These happened to be perched on the table in the room we were occupying as we reviewed charts.
When we asked the tech why she didn't take the book with her on insulin rounds, she responded casually, "I didn't want to bother you all. Besides, I know everybody's sliding scales anyway."
'nuff said. These are all great ways to bomb a survey or inspection and put one's license at risk. Don't let them happen to you!
