I'm a Medications Menace

JessiekRN · Apr 21, 2007

Okay I have to admit I am a bit confused by your post... "meds are all small stuff"?? What am I missing please?

SuesquatchRN, BSN, RN · Apr 21, 2007

I'm not the best person on earth for details. And passing meds for a bunch of people consuming polypharmacy is a lot of details. Small stuff.

cabkrun · Apr 21, 2007

YIKES. Having a heart attack because of a missed med is "small stuff". Maybe it's time you got out of nursing all together, because someone may not get better even if you do change nursing jobs, because you've missed "the small stuff". Overdose of chemo? Oh sorry, just a "small stuff" error.

I hope you are joking, really. And not a details person? How long you been in nursing exactly?

SuesquatchRN, BSN, RN · Apr 21, 2007

Hey, thanks for the tip, cabkrun.

Anyone out there who can help with what I already know is a problem, hence the thread?

regularRN · Apr 21, 2007

Passing meds is a major part of nursing in the US - use the five "rights", and keep checking and rechecking the MAR.

If you have electronic medication records it's virtually impossible to forget to give a med because the computer pops up an icon to indicate that meds haven't been signed off. Even so, I always check and recheck.

SuesquatchRN, BSN, RN · Apr 21, 2007

Thanks, Lotte. LTC - loose-leaf MAR's. I check every day after each pass but somehow am missing something.

Home Health Columnist / Guide · Apr 21, 2007

I hate the small stuff, and meds is all small stuff. I keep missing new orders that are handwritten in and start on the day I'm covering the unit.
I'm not the best person on earth for details. And passing meds for a bunch of people consuming polypharmacy is a lot of details. Small stuff.

Glad to see your looking for advice for your problem. I've highlighted areas that I see contributing to your problem. Changing your thinking on these issues will go a long way in problem resolution.

a.. Not being detailed oriented.

b. Meds as small stuff

c. Polypharmacy

1. Nursing is all about paying attention to details.

LPN's working in SNF assume the role's RN's perform in the hospital as the first line defense and patient advocate. From patient assessment & interview, review of lab work, following and evaluating treatment order results, communication with doctors /NP's /PA's re change of condition to med administration all require details for what we fail to do/communicate/pay attention to will result in PATIENT HARM.

2. Meds ARE big stuff as drummed into nurses in nursing school. Long term practice and rote med administration lulls many into complacency...who's trap you've fallen into by your post.

3. Polypharmacia, especially in geriatric population. When I started practicing in 1977, patients took 3-5 pills/day. Nowadays it is rare for those in SNF to be on less than 8 pills/day

8x40 pts = 320 meds passed in just one round

Looking at ways to minimize med errors.

a. Gear up in your mind that you are PATIENT SAFETY ADVOCATE at start of med pass. If you know that docs been in prior to or start of med pass, check patient charts before or immediately after med pass.

b. Do not allow yourself to get sidetracked/med pass stoped unless emergency. Pull out to side med kardexes with questionable orders, those expiring .

c. Check front and back card for notations/changes.

d. Have fully stocked cart at start of shift, including drug book, fluids, applesauce/pudding etc.

e. Give meds first to those you are going offsite or to early rehab sessions.

f. Discuss with doctors and pharmacist ways to decrease meds in patient getting more than 8 per day....should be a standard facility review as part of Quality improvement.

g. Write up sticky note and place on top of med kardex for outline med pass issues for day.

h. Develop a routine of checking orders after AM pass so can get sent off to pharmacy to have meds for later in day.

i. Last week of month, comb through 8-10 kardexes/charts day for monthly order renewal rather than waiting till last 2-3 days.

j. Plan for emergencies to interrupt day so don't get defensive when they occur.

k. One nurse kept tape recorder on top cart....just spoke into tape while pulling meds so no writing, ran tape when back at desk as reminder.

If above already tried then maybe SNF not a setting for you.

regularRN · Apr 21, 2007

I can't help thinking that forty pts is way too many for one nurse, even in LTC. Is there anyway you can delegate some of the med passing to another nurse?

SuesquatchRN, BSN, RN · Apr 21, 2007

Karen, thanks! This is really helpful.

LPN's working in SNF assume the role's RN's perform in the hospital as the first line defense and patient advocate. From patient assessment & interview, review of lab work, following and evalutang treatment order results, communication with doctors /NP's /PA's re change of condtion to med administration all require details for what we fail to do/communicate/pay attention to will result in PATIENT HARM.

Actually, an RN is charge and the LPN's in my facility dispense tx's and treatments, and order meds and tx supplies. The rest is all done by the RN. I can't start calmo on a red butt without the RN's okay.

I know LTC isn't for me, actually, but I have no options until I finish the RN. And even if this isn't what I want to do ultimately, I do want to do it well. My residents deserve good care.

Thanks again. I'm printing your reply out and carrying it to work with me.

Daytonite, BSN, RN · Apr 21, 2007

What I used to do was to take my finger or a small ruler and physically go down each MAR that had any handwriting on it looking for any listing of a written in medication that I might have missed. Knowing that you are likely to miss something like that is half the battle. The other half is doing something to prevent it. I just made the effort to take the time to scrutinize those particular pages. I also carried a yellow highlighter so I could yellow out D/Cd meds. Get them marked out so you don't have to keep reading over them.

I also took a personal interest in keeping the MARs straightened out. If there was a handwritten MAR that was looking pretty raggy and confusing, I would re-write it. No one knew what was on the MARs better than I did. It was because I made the effort to do it. I got involved with calling the people at the pharmacy and finding out what I had to do to get their computers to print things out on the monthly MARs the way I wanted them to print out. It took a few months to get it all straight, but it finally paid off. In case you haven't figured it out from some of my other postings, I like to be in charge of things.

Also, the biggest med errors are made on the newly admitted patients. At least, that's what I found. So, I watched those MARs really closely and checked the charts if I felt I needed to. Once I was settled into a job I used to check for new TOs, watch that illegal report book for anything about doctors being called or patients with fevers, and check the fax machine for faxes that other nurses might have sent to doctors about patient problems that they forgot to pass on in report. Outside of that, I often would do a quick chart check for new orders just like I did in the hospital--honestly, it only took 5 or 10 minutes and I was only specifically looking for newly written TOs that would have been at the very beginning of the doctor's orders section of each chart. I usually did that after I had been off a day or two. If I was working days, there was a box that the original copy of TOs went into that we could also go through before someone from the office came in at 8am and took them to mail out to the doctor's offices. Another source to check for new meds is whatever is used to order from the pharmacy. A new order for an antibiotic or other med will be on one of those pharmacy order sheets (unless someone missed the order in the chart).

Good luck, kiddo. I know your worry and frustration. Maybe going one step beyond just doing the med pass will help you get inspired. Like with me, I really got into the organization of the MARs and reconciling the monthly order sheets. I also routinely cleaned and organized the med cart for my unit. It wasn't something that was required of me as a charge nurse, but it was something that I saw needed to be done and no one was willing to step up and do it. One thing that I always liked about LTC was that there are plenty of opportunities to cut oneself a little kingdom to run. All you need to do is find what it is that interests you and run with it. Become the facility expert on that particular thing. It will give you great satisfaction, make the more mundane parts of the job (passing meds to 40 patients) better to swallow and the boss will like you better as well because you are showing some independent initiative, especially if it is something that will help come survey time.

SuesquatchRN, BSN, RN · Apr 21, 2007

Daytonite, thanks so much. The ruler! I'll do that. And checking the order sheets - excellent idea!

One big annoyance here is that there IS no book for TO's - the doc give them to the charge nurse who writes them directly into the chart.