Missed Orders; How do you do it where you work

[annmariern]

Hi, sorry if this is long, need advice or a new job!

I work a 30 bed PCU/Ortho/general sugery floor. Massive problem with missed orders, so bad the boss is experimenting with the staffing to try and fix it. Our ratio was recently dropped to 5:1 days, 6:1 nights, with 3 cnas days/ 2 at night. A UC days, and at night till 11pm and a charge nurse both shifts. Very heavy unit.yesterday I had one CNA with 15 pts, only one of which was walkie takie, the rest 2 max assist and several inconinent We had the UC imput orders, each nurse checked, signed off at change of shift; nights were to do a 24 hr chart check. Major orders being missed; often. So we tried upping the nurse to 6:1, again, 3 aides. Trouble with that is we are expected to have perfect documentation, JCAHO perfect. We give massive amts of narcs and the pain evals alone can be a nightmare. One nurse was now off care doing chart checks and helping out. Trouble with that, too many fingers in the pie, the nurses who are conscientious and checking their charts as part of the job continued to do it, others just let someone else sign off for them, get the resource to pass meds, start IV's for them,basically sit back. A couple of things changed that contributed, they got rid of duplicate order sheets (money saver); they hired a new UC who had never done it before and gave her 5 days training. Not knowing a med from a lab, bound to be mistakes. And the fact that people who just sign away without checking and get away with it as no-one actually tells them when it gets caught! So both trials have been rough, I feel punished almost because Im one of the mugs who is anal about charts, so the extra nurse isnt much help to out I have an extra pt, or an aide with an impossible workload. So does anyone have any ideas, how does your unit do it, does it work?

[Riseupandnurse]

We switched computer systems and now everything's supposed to be put into the computer and checked. It's loaded down with so much garbage I can't even tell what the orders are. I don't think anyone else can either because nobody's getting "dinged" over it, although I'm sure orders are getting missed.

[OldnurseRN]

We have 3 nurses per shift with a CNA and unit secretary on days. One nurse is "charge" and does the ED and out-pts and admissions/discharges. Orders are entered into the computer and signed as trasncribed on the orders. A second nurse then has to check the order entry and notes it. We are a 25 bed hospital. I routinely check my charts for orders and then check the status on the computer to be sure they are, indeed, ordered. It seems more medications missed being given (because of the way our computer program, CPSI is, than orders being missed.

[Vito Andolini]

This all sounds like a good reason to go back to doing it the old-fashioned way - by hand.

Something that will help is to get doctors to show their new orders to the appropriate nurse (the one who has that patient) or to the Charge Nurse.

And, of course, it would help if the clerk knew medicalese. How insane, how irresponsible, how uncaring of patient safety or nurse stress to put someone on this vitally important job without proper training. Sounds like JCAHO might want to know about that. And CMS and your state Dept. of Health.

It takes a lot longer than 5 days to learn Medicalese, I think.

[WindyhillBSN]

What is the manager doing? Can he/she not check the charts?

[annmariern]

Thanks for your responses; I agree about the UC; at least a medical terminology course as a pre req for the job. As well as imputting orders, she has to answer the phone, the call lights and route people to rooms via beeper messages. Our manager is running two units, we hardly see her. I thought I'd ask in case anyone has a brilliant system out there, but I am leaning toward the you just have to check your charts and be responsible for them system! I have been disturbed actually by just how many nurses don't ever look at their orders during the day and just sign away without checking. We had an incident where a pt recieved lovenox after the nurse acknowledged it on emar without checking the chart; pharmacy error put it in on the wrong pt. Oops.

[Aniroc]

Before nursing, i was a UC and medical terminology was a big part of my certificate course (which was a total of 9 months long) as was pharmacology. To NOT know the differences between lab work and medication is, in my opinion, unacceptable for a person in this position. Unit orientation should just be about getting to know the unit, the specific paperwork for that unit and basic office/hospital routine. This should be reported to the manager as the UC really needs to take charge of ensuring that the paper work and orders are done correctly so that nurses can do their jobs - and thats nurse sick patients! There isn't enough time in a shift to constantly question your UC's work! Unaccetable!

[Up2nogood RN, RN]

You're lucky we don't have a UC at all. We do have a secretary during the day that answers phones for 2 units. Not much help to us at night though. We went to computerized entry. There's been some bugs with the post op order entry forms, but otherwise docs enter their own orders even from home, only occ phone orders. I round once on my pt's charts at BOS and since I work at noc I just need to check hourly on the computer for new orders which I do anyway d/t charting. So much easier than trying to decipher crappy handwriting!

[Aniroc]

Here in Canada (at least where I am) we aren't so fortunate to have a fully computerized system, though I am looking forward to it. Stuff like this takes forever in my country. For the most part, the docs still hand write orders and the UC enter in the lab and medications, OT/PT and other consults are done. But everything still remains on the order sheet and the nurses still have to ensure that the orders are entered. Its such a time waster really. The best thing any nurse can do is to keep on top of their charting going back to the order sheet frequently to keep on top of new orders. A good UC (as I was - don't mean to brag but I was, lol) will advise the nurse directly of new orders with a quick heads up as well as pulling the chart flag.

Missing orders makes for serious issues in patient care and nursing resources, being anal about this issue just makes you a prudent nurse. Keep at it.

[Riseupandnurse]

All medication orders in our hospital have to be sent to pharmacy by a nurse, not a ward clerk. This is because we could never get the ward clerks trained enough to be able to tell the difference between medication and lab orders. Really wastes a lot of time because of all the walking to the fax machine and back down the hall to the charts.

[sasha1224]

At one hospital I worked at, it was all computerized. Anytime you accessed the patient chart it had a flag to tell you of new orders. This was great. The next place I worked, the orders were on paper, and the UC took them off. They did have to know the basics. They couldn't transcribe meds but would write them in red on the MAR and this would alert the nurse to a new med order. It also helped that a copy of EVERY order went to pharmacy. This helped in case they missed one. At my current place, we have a UC only about 6-8 hours during the day. Us nightshifters, never have one. We are responsible for any orders written. I think since we know we have no UC, we have gotten used to doing our own orders. However, our day crew seems to depend on the UC that is there for such a short time. I catch many orders on PM shift not done during days. I would say that the computerized way was far superior, wish it was mandatory.