I'm a Medications Menace

[SuesquatchRN]

This new facility documents all med errors. I find one every day but frankly don't report them because I really don't like narcing on my coworkers over a missed vitamin. But anyway. I will be starting as of ystdy.

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.

Any suggestions? I'm banging out pills for up to 40 folks per meds pass and I don't know what I'm doing wrong. When I think I've done right I mess up.

And I'm sick of LTC. I've been wondering what it would be like to care for someone who could actually get well instead of literally go into heart failure if he misses a freakin' Lasix.

[sirI, MSN, APRN, NP]

One thing I might add, sue.........

If you are distracted during your workday (personal distractions, etc.), your margin for error increases.

As has been stated, step back, take a deep breath, and RE-focus. You are the patient advocate. The patient comes first. Medication administration is all-important even to the most mundane detail.

I can sense the frustration in your post(s) regarding this.

You've received some excellent responses from NRSKarenRN and Daytonite.

Good luck and here's a ((HUG)).

[weirdRN, RN]

I have no options until I finish the RN.

Actually, You do have options. Do you live near a prison? How about a doc's office?

Right now, there are a good many positions open to anyone who has a license who is also willing to get in there and do their best. I loved LTC but hated the thirty resident pill passes and the whole do more with less culture.

Here is a link that might help you: http://www.cmsstl.com/

I wish you the best. And if you do decided to apply there, pm and let me know.

Kristie

[pickledpepperRN]

Medications for forty patients is a BIG job.

It was almost too much for me on a 27 bed unit years ago when I was LVN med nurse. And we had a good system. Sometimes doctors would take a chart, write an order, and put the chart back.

I think 40 is too many. What does the policy and procedure for medication administration and documentation say?

I would try to get a private duty job. It just seems like too much and you don't want to miss a needed med.

Is there another nurse on the shift with you?

See, I'm not thinking in an organized way either. Just brainstorming.

Since you find errors others have made it seems like your facility needs a better system.

[TrudyRN]

Karen, thanks! This is really helpful.

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.

I agree with Karen and would add that you should check with your boss for advice on how to avoid errors. What will you do when you get the RN? Where work, I mean.

[nursemike, ASN, RN]

Sometimes it feels like a barroom fight trying to pass meds to six patients! A few of my co-workers draw up grids with patients down one axis and times on the other, then put "x"s wherever it's time for a med. Don't know how practical that would be for forty, though. We have to check off our meds on the computer after they're done, so I try to keep in the habit of doing that immediately after each pass. Occassionally find one I overlooked in my orders, and somewhat more often find ones that were ordered that I didn't get the order for. I'm better off giving a 2200 med at 2300 than just discovering it at 0645. Now I'm trying to work on checking the cart ahead of time, because it seems like I'm having to reorder a lot from pharmacy, lately, and it's nice to know about it ahead of time. Last night I had to call 3 times about a pt's own med from home that we were supposed to dispense from pharmacy--for safety. They hadn't seen it, never heard of it, oh, it's at the patient's bedside, per physician. Then, at 0600, this QHS med shows up in his drawer. Oh, well, at least it was nothing critical...

Good luck with your situation.

[nightmare, RN]

Wow,you guys seem to have very complicated drug rounds compared to ours but then that's maybe the difference between LTC and our Nursing Homes.If ours are prescribed a new drug or new dosage it is always the last on the chart with that days date.If it is a new dosage the old dosage is crossed out and the new one written in on a new line.

Every other week we do a drug count and an order to the pharmacy for that months drugs.If there is a change by the doctor then a script is picked up that day.

Most of ours are on at least 8-9 different drugs daily.

[morte, LPN, LVN]

sue....noting your age, the presumtion of wearing glasses.....when was the last time you had your prescription checked? and are you trying to pass meds with insufficient lighting? good luck

[SuesquatchRN, BSN, RN]

sue....noting your age, the presumtion of wearing glasses.....when was the last time you had your prescription checked? and are you trying to pass meds with insufficient lighting? good luck

Heh. My vision is fine, morte. Thanks. I think.

And thanks to everyone else. My usual pass is 30, when on a certain unit, 40.

I have to say, this place is really well-staffed comparatively. Days each unit (30 - 40 residents) has three nurses - 1 LPN for tx, one for meds, and an RN as charge.

One problem I have is that I am "regularly scheduled part time" - 6 days per two week pay period. The other days are per diem. I took this largely because we need medical coverage and that offered through my husband's job really bites - we ended up out of pocket thousands last year under his, which cost about $400 a month. I pick up a policy through work at $850 a month including dental. I pay it all. Mike has several things going on that cause him no problems as long as he takes all of his meds and gets all of his stress tests, etc.

Anyway. I end up floating around to different units a lot. Not counting today, over the last 9 days I worked 8, on all 3 units. I'd get one down and be on another the next day. And meanwhile the other two - on which I'd never done meds until this week - have a lot of dialysis patients, with whom I've never dealt before and, because of certain meds being dialyzed, stuff was being given at times to which I was totally unaccustomed - synthroid at night? Oy! And the sheer numbers of pills these guys get - each meal, each snack, before and after dialysis, a.m. and p.m. and h.s. - I was really thrown.

Meanwhile, like daytonite, I HATE disorder and, coming from a corporate background, I can't believe how freakin' catch-as-catch-can the systems are here. "Look in 'the black book' in the morning. Write down appts on this sheet. Look the 'the b.m. book' and get the hematests and put it on the sheet. Whaddaya mean, how do we know who gets a hematest? It's in the b.m. book!" Yeah, but how does it get into the b.m. book to start with?!

When we order meds the sheets go into a pile. We check off when they come in. NO ONE not on days follows up. Now, if Prilosec is given 6 a.m. and you've been out for two days and I ask if you could leave me a post-it on the MAR to remind me to follow up do you need to answer, "I do that when I put the order strip on the sheet." ARRRGGGHHHH!

Another problem is that my usual unit is on the busiest hall in the facility and I am constantly being interrupted by PT ambulating a patient through where I am at the med cart, cleaning crew wanting to get into the janitor's closet where I put the med cart, aides wheeling a resident into the cart, the several ladies who do Senior Olympics around the corriders in their wheelchairs coming down the hall like blind, deaf and dumb tortoises when I'm trying to move the med cart, the charge nurse snagging the MAR to write down a change while I'm in the middle of a.m. pass ....

I guess I'm just kind of fried, as has been suggested. I do plan to take all of the suggestions, and I printed out Karen's response and write in RULER! READ ORDER SHEETS IN A.M.! on the bottom.

It's just hard. I have people who are barely alive and can't even swallow their bazillion pills in one crushed, pudding-filled bite because even crushed they can hardly swallow them. They can't walk, talk, think, crap, eat - I dunno. I've lost any romantic notions about the noble elderly. Some are wonderful, some are nasty - just like everyone else. But I get upset by the demented, frightened ones who can't be helped yet are kept hanging on and hanging on, scared and unhappy. I don't know the answers. I'm not sure I even know the questions anymore.

But again, thanks for the suggestions. I'm on again Tuesday - thank goodness for a long weekend - and I'll let you know how they go.

[SuesquatchRN, BSN, RN]

Wow,you guys seem to have very complicated drug rounds compared to ours but then that's maybe the difference between LTC and our Nursing Homes.If ours are prescribed a new drug or new dosage it is always the last on the chart with that days date.If it is a new dosage the old dosage is crossed out and the new one written in on a new line.

Every other week we do a drug count and an order to the pharmacy for that months drugs.If there is a change by the doctor then a script is picked up that day.

Most of ours are on at least 8-9 different drugs daily.

That's the same here, nm.

[Trying2BLPN]

Hmm. I woud love to complete my med. pass without distractions, unfortunately I am required to answer call bells and toilet, etc. patients while I am in the hall doing my med. pass. because the corporation doesn't want to hire enough CNAs.

I swear I see MARs in my sleep and daydream about lines and little boxes on my days off.

I would love to take charge of making sure our completely jacked up MARs were straightened out but unfortunately I can't squeeze and extra minute out of my day and I already stay over an hour late every night just charting (I'm on a medicare floor and a full head to toe narrative note is required on every pt. every shift.)

I really think the way these places are set up they are just about asking for a catastropic medication error to occur. I think the entire system is broken and needs to be rebuilt from the ground up.

[SuesquatchRN, BSN, RN]

(I'm on a medicare floor and a full head to toe narrative note is required on every pt. every shift.)

Holy guacamole, Batman!

[suni, BSN, RN]

I think you need do need to get out of LTC. I was an LPN in LTC and passed meds for 50-60 people. I hear what you are saying about BM book, treatment book and we also used the paper MAR binders for meds. The RN would take off the orders and flag it as a new med and leave us a post it to let us know the patient and that we should double check.

I guess what I am wondering is if you are agency? It doesn,t sound like you are being properly oriented to the units you are working. I know the expectations for agency nurses is that you hit the ground running but God forbid you make a serious error the LTC facility has some liability if they did not give you proper orientation.

Meds are a hugh deal and safety is imperative.

The only other thing I have to offer is that Incident Reports should not be viewed as punitive but as a learning tool. The idea is that your QM people will look at them and do a root cause analysis and hopefully help with implementing a plan to improve med safety.