Nurses don't do their 3 med checks?

[OsceanSN2018]

I've been to two higher acutity clinical sites so far on a med-surge/oncology floor and a cardiac observation unit (step-down CCU), and some of the nurses seem to not do their three medication administration checks. I didn't give it much thought until my second clinical rotation and now I'm wondering if this is considered "normal" for some nurses? For instance, I shadowed a charge nurse in the CCU and she would just open up the patient records on the EMR then take medication out of the pyxis without even reading the labels on them. I asked her why don't she read the labels and she said that she been doing this for a long time and know how each medication package looks like... So then went to each of our patient rooms and gave the medication to them without asking for their name/DOB. She just scanned their bracelet and administered the medication without telling the patient about the meds. Plus, she made me administer heparin in an insulin needle saying it's "fine".

She is not the only nurse who I've have seen not doing their 3 med checks, and I wonder if this could become a problem?

[Susie2310]

Just to let you know - this article is currently one permanent favorite of professors of statistics all over the country to be used as an example how NOT to use or interpret public health data after you somehow got your hands into it. Unless you want to be a laughing body for everyone familiar with more stats than famous 3Ms, that's it.

Here is a nice summary of what is wrong with it:

http://www.amjmed.com/article/S0002-9343(16)30705-7/fulltext

I highly recommend you to read this piece as well:

/plosmedicine/article?id=10.1371/journal.pmed.0020124

So what do you find erroneous about the John Hopkins study?

[KatieMI, BSN, MSN, RN]

So what do you find erroneous about the John Hopkins study?

Well, to begin with, it is not even a "study" in methodologic point of view. It is non-peer reviewed two guys' opinion who, using "methods" taught in US Grade 11 AP Stat class as wrong one to use extrapolated 250000+ deaths/year from 35 cases which they randomly pulled out of 4 poor quality articles > 8 years old.

I would be wondering what exactly the editor was drinking before letting that piece of paper to be published in BJM but after the story of The Lancet and former Dr. Wakefield I am not surprised. Thanks God that leading American medical peer reviewed journals (which rejected the article in question) seem to have higher standards.

[KatieMI, BSN, MSN, RN]

Well, regardless of what you want to believe, which is your prerogative, the study exists and anyone who is interested can read the study for themselves and inform themself of the data that was examined and the methodology used.

What a pity that I am so tired. I'd seen, for one example, academically impeccable article declaring and subsequently providing numerous proofs that the Earth is flat.

[Buckeye.nurse]

What a pity that I am so tired. I'd seen, for one example, academically impeccable article declaring and subsequently providing numerous proofs that the Earth is flat.

I just wanted to comment that I agree with you KatieMI. It's been a long time since my introduction to public health class (which heavily covered designing and carrying out clinical trials). I remember the P value though, and many studies published have borderline P values that don't really prove much of anything.

I also remember several of the instructors in my RN to BSN class saying that if we are struggling to find published research that backs our PICOT question...we probably need to rethink or question, instead of continuing to try to find *one or two* studies out of hundreds that backs us up.

Here's a link that ties back into what you were trying to say KatieMI.

Believe It Or Not, Most Published Research Findings Are Probably False | Big Think

[ruby_jane, BSN, RN]

Oscean-

Did you ever see "Bull Durham?" Classic 1980s movie where Kevin Costner is the world-weary baseball ace and Tim Robbins is the up and coming stud young pitcher? Costner's character goes off on Robbins' character about how sloppy he is, lack of work ethic, etc. "When you're in The Show (major leagues), you can let the fungus grow on your shower shoes and people will think you're colorful. Right now, it makes you a slob."

You will pick up a lot of bad habits from seasoned nurses if you let yourself. You will also get some great tricks - up to you to decide. Hold yourself to the standard that they teach you. Nothing wrong with asking the question.

[missmollie, ADN, BSN, RN]

The checks:

1. Pyxis. Let's you know who you are pulling the meds out on.

2. Scanner: you scan the patient's band before you scan the meds

3. EMAR: let's you know if it's correct or not with a lot of error messages.

Ask a nurse what they would do if the scanner or EMAR was down. They'll triple check. You are a student, and you will quickly learn the ways of the actual nursing world. You are not right, you are inexperienced.

[mushyrn, BSN, RN]

Personally, I check the medication packets for each pill, mostly as I pull them from the Pyxis and always as I'm scanning them at the bedside. If you have 50 pills to pull, checking every packet both at the Pyxis and in the room can be time daunting. I ask the name/DOB the first time I encounter each patient, and hope that my mental faculties are able to keep up with that for the rest of the day - because asking every single time pisses patients off and makes me question my intellectual abilities.

Let's not go into the staff who ask unresponsive, vegetative patients their name/DOB every time they go into the room. Jeez.

Just be safe, and know that you're giving the right medication to the right patient.

[RNrhythm, BSN, RN]

I always double check what I pull from the Pyxis. I don't have time to make multiple trips (forgot the second pill, something fell into the wrong bin etc.).

[Mini2544, ASN, RN]

During my clinical rotations, I saw quite a bit of this type of situation happening. Some nurses feel like they have enough experience where the safety checks don't apply to them. To top that off...one time as a student I had an instructor tell me I was too slow at giving meds because I wanted to make absolutely sure the meds I was giving, were correct and safe for the patient. That was a terrible clinical experience, but anyways...don't let other nurses bad habits change how you do things. Sometimes it takes only a few seconds to double check a patient identifier and it could be the difference between life and death.

[Irish_Mist, BSN, RN]

I was not teaching anything to the charge nurse as I was just shadowing her. Plus, I did all what she wanted me to do. And you are very rude. I guess the saying is true that nurses do eat their young...

Students like you are why so many nurses moan and groan when they are assigned a student. Seriously, enough with the NETY. It's getting so old. Actually, it has already gotten old.

[JKL33]

Well, to begin with, it is not even a "study" in methodologic point of view. It is non-peer reviewed two guys' opinion who, using "methods" taught in US Grade 11 AP Stat class as wrong one to use extrapolated 250000+ deaths/year from 35 cases which they randomly pulled out of 4 poor quality articles > 8 years old.

I would be wondering what exactly the editor was drinking before letting that piece of paper to be published in BJM but after the story of The Lancet and former Dr. Wakefield I am not surprised. Thanks God that leading American medical peer reviewed journals (which rejected the article in question) seem to have higher standards.

Ditto.

[brillohead, ADN, RN]

Some thoughts on things I've seen in this thread....

I can tell you exactly what bin holds the Tylenol in all three of my unit's Pyxis machines without looking at what bin is listed on the screen. I can also read the medication name and dose on the packet as I'm tearing off the necessary number of tablets/capsule without missing a beat.

Some of my patients are such regulars that I can tell you their name, DOB, their daughter's name and what city/state she lives in, the ages/genders of the grandchildren, etc., without ever looking in the chart. For those patients, I typically scan their bracelet and say, "And are you still the same John Doe I took care of yesterday / last week / last month?" with a chuckle, because they know as well as I do that I know exactly who they are without them saying a word.

Ditto with patients that I've had for several shifts in a row. And for patients who I've already identified earlier in the shift -- I only ever have six patients at a time, and never two with identical names. By the time I'm putting the med in the cup, I've already checked my handwritten brain (which has their name and DOB and room number on it -- we only have private rooms, so no bed number necessary), plus I signed into the Pyxis to get meds for that patient's name, plus I read the med as I pulled it off the multi-dose card, plus I scanned the patient, plus I scanned the med, plus I made sure that the med that I scanned was the one in the eMAR... that's a heck of a lot of checks!

As far as reading the meds off to the patient, some of our patients don't want us to -- we're interrupting their episode of Law & Order or whatever when we read off 15 med names. Or for dementia patients, they don't know the meds they take anyway. But for A&O patients who haven't already told me not to read the meds off, I do name each med and what it's for as I scan each one (I've got your hydralazine for your blood pressure, and your metoprolol for your BP/HR, and melatonin to help you sleep, etc.), then I ask if all those meds sounded appropriate or if there's anything that they think I missed.

As for medication errors, you might want to look into what exactly counts as a medication error.

In nursing school, they pounded into our heads that you had the window of one hour before and one hour after the scheduled time to administer the med "or it's a med error". Using that guideline, I'd say that most hospital patients do experience a "med error" during their stay.

However, I know that on my unit, we average between 1-1.5 ACTUAL medication errors (wrong medication, wrong dose, etc.) per month for the whole unit, and none of those have resulted in any actual patient harm in the two years I've worked there. However, I have seen patients die from MI, COPD, cancer mets, GI bleed, sepsis, etc. -- so much for med errors being the third leading cause of death!

For that matter, what are we calling a med error? What about people who have A-Fib and aren't on anti-coagulation therapy and they end up with a stroke / PE / MI as a result? Their PCP is the one who didn't prescribe them the coag meds... not the fault of the hospital nurse/doctor. How about the number of people who are prescribed narcotics and anxiolytics byb their PCPS, and the patients overdose and die from the OD? That's also a prescribing error, not an administration error. Or people prescribed a betablocker but aren't taught to check their pulse every day (or they were taught but they're lazy and don't do it) and end up bradying themselves into a cardiac arrest? Technically the medication caused their death, but it wasn't necessarily prescribed in error.

Don't assume things.... you are young (in nursing) and don't yet know what all you don't know.

Oh, and I give heparin with a 100-unit insulin syringe because my unit doesn't carry subcutaneous needles. When I give heparin with an IM needle, it causes the patient unnecessary pain and is more likely to bleed afterward. Most of my patients tell me they never even felt me give the shot (I push it slowly so it doesn't sting), and they rarely bruise from it, either. Again, you are young and don't know what you don't know -- the order is to administer it subcutaneously, and I administer it with a subcutaneous needle. No problem at all.