Computer charting for meds and no paper Kardex

[newrn05]

At alot of the hospitals in my area they are going paperless. Even for meds. I feel this is unsafe. I am in a habit (from nursing school) of having a paper Kardex with all the meds due for the shift in front of me. I use this paper to keep track of my meds and my checks. It also has the patient info used to identify the patient. I have found that I have almost made many more medication errors with this paperless systems.

Does anyone else think that going completely paperless and not having anything to write in or mark on for medication admistration is unsafe.

[WSU_Ally_RN, BSN, RN]

is there a way to print the med sheets off the computers?? Where I work, we are slowly converting to computers and no paper, but we are able to print everything off the computer that we can look at, so we are still able to keep a copy of the med sheets for ourselves if need be... Or, could you, at the beginning of your shift make a chart for yourself of the times your pts get meds, as a reminder to yourself, without actually copying everything down?? This is what a lot of the nurses do, and they seem to do fine.

[SharonH, RN]

Kardex or MAR? I would never give meds from a Kardex.....I hated the darn things anyway they were always so untidy. The electronic systems for giving meds can be quite safe as long as you continue to observe the 5 R's but I am not sure of what type of system you are using.

[suzanne4, RN]

All of the information that you need as far as checking your patient's information is located on the paperless system, at least at the facilites that I have been at. It should list pertinent information about your patient, such as their medical record number, allergies, even birthdate.

Meds should be signed off and verified by an RN when they note the orders in the chart, or on the computer, which ever type of charting that you are using. In the systems that I have used, the medication could not even be charted until it had been verified by an RN.

I know that you are in a habit of using the old paper kardex, and it will take some getting used to. Same for me currently, as I have been used to computer charting for meds, and now I am using the old system with 100% paper. And I hate it. Much more room for error in my opinion. I will take the computer based programs for meds anyday.

[newrn05]

The system I learned on took the meds in the medication system and the POC and merged them and printed them on one easy to read and follow Kardex. It would include any labs for the shift and dressing chagnes, etc. The thing i liked about it was i could highlight what needed to be given at a certain time note in the margins any labs that i needed to check prior to giving, etc as well as check off as i pulled out my drug, cross off and i double checked my drug and then put a solid line through as i tore open the packet at the bedside.

I find the computer systems i have used so far unsafe becuase there is no way to print up the medication list so you dont have anything to take bedside with allergies, any pt identifiers. I have started using a label but that still does not have alergies. nothing in these systems taht they use allow you to print. I have tried to make my own list but we are human and i ahve missed writing down things before.

[suzanne4, RN]

What type of computerized system are you using now? Is it hand-held?

If not, you can try just listing the allergeis on a patient label, that way you also have the patient's information with you.

What has your manager suggested that you do?

[ilostu12]

Computers? Paperless?? OMG, we're still in the stonage, Mars, narrative charting, hand written admissions......

[SmilingBluEyes]

Even Meditech has a way to print MARS and check medication admin times/amounts. Surely your system has ways to do this, too. Request a thorough inservice to be sure you know WELL how to use this system before taking responsibility for it.

[RNKITTY04]

We recently went paperless also, at first I did not like it but am slowly adjusting. The next med that is due is always the first one to come up at the top and if you try and give the wrong med at the wrong time it just flat out will not let you (unless you go to another screen and mega chart) so I see little room for errors.

I also like the feature that I can right arrow into the med and see when the last nurse gave it, what dose and what time.

My biggest complaint is the system is big and bulky, its hard for the smaller nurses (such as myself) to try and push it around all the crap in the rooms especially at night.

But I think its here to stay, It must have cost a fortune for each nurse to have one.

[HappyNurse2005, RN]

We have MAK's, which are paperless, but we also have printed med guides we can go by, that have all the meds for the 24 hours. You can use the MAK w/o hte printed guide, if you want. Can't do the printed guide w/o the mak though, as we have to scan the med and scan the patient.