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  1. SUSAN “Our problem child is back.” Ann whispered as I sat down at the nurses’ station to chart. “You mean Susan? I hope she’s okay, I’m worried about that girl.” I said. “Will you take her? I’m getting so sick and tired of dealing with these freshmen. I think most of the time they just miss home and want someone to talk to. I’m not in the mood to be mommy today.” I raised my eyebrows at Ann, thinking for the umpteenth time that she was really in the wrong business if she didn’t want to talk to students, but nodded affirmation. I reviewed Susan’s chart. This was her fourth visit in one month. She was an out of state student, here on scholarship. She had first come in just a few weeks after the semester had begun. She stated she had fallen in the stairwell after a dizzy spell and hit her head on the railing. I had seen her then and assessed her for a concussion, but she was asymptomatic, with no loss of consciousness, just a large lump on her forehead and a headache. I educated her about the signs and symptoms of concussion and brain injury and then asked if she had anyone she could check-in with in case symptoms did arise later. “Have you made a friend yet? Someone who checks up on you and vice versa?” She looked away and shook her head. I asked about her parents and she had expressed anxiety over being away from home for the first time. I asked her about the possibility of a visit home, or her parents visiting and she had looked sad and uncomfortable, saying, “I love my mom, I really miss her, but my dad, well it’s my stepdad actually, he and I just don’t get along.” Something about her pulled on my maternal heartstrings. She seemed so bedraggled and lost. She had shared that her father had died when she was quite young and her mother had remarried a few years ago. I encouraged her to call her mom, just for a chat and she had promised to think about it, though her parting words had worried me, “He wouldn’t like it.” I wanted to follow up on that statement, but the clinic was busy, and the PA was motioning to me to hurry up for a procedure and I had to let it go. She was coming back in a week for a follow-up and I made a note in her chart “ask about the home situation.” Unfortunately, when she returned the following week, I had been out sick, so I read through the chart and saw that she had stated “no problems” from the head injury. The nurse had charted a subjective note about a different problem - deja-vu. “It’s so weird. I know it’s silly, but I will be walking to class, or sitting and having lunch in the caf and I will just feel so strongly that I’ve been there before. It happens at least once a day.” A few weeks ago, she had returned complaining of a rapid heart rate and feelings of impending doom before taking a biology test, and that time it had been my day off. The PA had talked to her about test anxiety and referred her to a counselor. Ann documented education about meditation and calming techniques, but there was nothing about her home life. Her vital signs had all been within normal limits and there was nothing unusual about her health history. She was on no medications, no birth control, and had normal menstruation. I approached Ann to clarify, “did you talk to Susan about her home life, her social situation? I’m worried about her. Something’s off with this one.” “No, both times I saw her, the clinic was slammed. Honestly, she strikes me as a lonely, scared little girl who is homesick. I think it’s all in her head.” Ann had worked here a lot longer than me, and I wondered if I would become that jaded if I stayed. “It’s not just about physical health, Ann. I’d like to think we are here for mental health, spiritual health, all of those things.” I replied, deciding that advocating for Susan was a better choice than keeping the peace with Ann. She signed and rolled her eyes, “That’s what the school counseling center is for. I barely have time to chart vital signs, much less be a therapist.” She grabbed her laptop and hurried off to see her next patient. I opened the door to call Susan back and saw her sitting in the waiting room, tapping on her smartphone. Her greasy hair was pulled back in a ponytail, and her shoulders were slumped. She looked exhausted. As she walked to the vital signs station I asked, “Susan, how are you feeling today?” “I’m okay, I guess. I’m sorry I keep coming back so much. I’m kind of freaking out. I’m not sure what’s going on.” “Are you still having deja-vu?” “Yes, that’s still happening, and, I’m still having dizzy spells.” “How about the anxiety? Have you had a chance to see the counselor?” “Yeah, I’ve been to see the therapist, and she gave me some good ideas for calming myself before exams, but I’m still struggling with anxiety. It’s happening at odd times, like not just before tests, but when I lie down to go to bed, or when I’m walking home from classes. And there’s this new thing. It’s so weird, I don’t even know how to tell you about it.” “It sounds like you’ve had a frustrating semester so far. I’m glad you’ve come here, that you’re reaching out.” Susan looked at me gratefully, and I could see her body relax a little bit. I got her vital signs and motioned her into the exam room. Once she was seated I looked at her and said, “Tell me what’s been going on.” She said, “Okay, but I think you’re going to think I’m crazy when you hear this. When I listen to my favorite album, I’ve been getting into Queen, listening to them a bunch since the movie came out.” “Oh, that was such a good movie. I’m glad you younger kids are getting to hear some Queen!” “Yeah, I’ve seen it like, 5 times.” Susan looked down, and I noticed her hands twisting together. I decided to wait her out until she finally said, “So whenever I listen to Bohemian Rhapsody, I smell peppermint.” She blurted the last part out, looking up at me with wide eyes. There was a faint flush of embarrassment on her cheeks. “It sounds like you're saying that when you listen to that song, you have the sensation that you are smelling peppermint. Does it happen at any other times? To any other songs?” “No, just that song. It’s so bizarre. It’s so strong. It’s like I’m sucking on a candy cane, or I’ve got some peppermint oil on me somewhere, but there’s nothing there. It’s just so…I don’t know. I feel like I might be going crazy.” “You sound scared.” “Yeah, I’m alone here, you know? My parents aren’t…” She trailed off and stared at the wall. “Did you have a chance to call your mom?” I regretted asking as soon as the words came out because Susan instantly tensed up. “I did call her, but…” she trailed off again. I nodded encouragingly, “What happened Susan? Is there something going on at home that you want to talk about? Whenever you talk about your dad, you tense up.” “Not my dad, my stepfather.” She said and I could hear anger in her voice. I waited, mustering up as much nursing presence as I could. Letting the silence spin out. In a small voice, so low I could barely hear her, she said, “My stepfather…he um. Well, he hurts us.” Now it was my turn to tense up. My internal alert level went to Defcon 5 and I felt like an alarm bell was going off in my brain. I had trained for this but had never had a patient tell me about abuse before. I wanted to get this right. Susan burst into tears. I put down my computer and asked, “Can I put my hand on your shoulder?” She nodded and I handed her a tissue as I did my best to comfort her with that small touch, sending out healing energy through my hand into her shaking back. “Susan, I’m here for you and I’m listening.” She clutched her stomach and said, “It’s happening - the deja-vu, and I feel so dizzy. And my stomach hurts so bad.” She leaned over and then suddenly slumped forward in a full-on faint. I assisted Susan safely to the ground, and then alerted Ann to the situation. She called 911, and we got a set of vital signs while we waited for the EMTs. Susan’s BP and pulse were elevated, but respirations, temp. and pulse-ox were normal. I told Ann what Susan had said, and she went to get the NP as I tried to arouse Susan. I kept calling her name while protecting her head and neck. Her eyelids fluttered and she finally opened them, asking, “Where am I? What happened?” WHAT’S GOING ON HERE? After reviewing all of Susan’s symptoms and assessment data, what do you think is happening? Is it related to the fall in the stairwell? Is it a brain tumor? What other information do you want? What’s next for Susan? In the hospital, Susan got the full workup – labs and a CT scan. The NP also recommended an EEG. What do you think they found? If you enter the following symptoms into google: dizziness, nausea, deja-vu, panic attacks and synesthesia, (the production of a sense impression relating to one sense or part of the body by stimulation of another sense or part of the body – as in when Susan heard the song but smelled peppermint) you get what you’d expect: brain tumors being number one, migraine is on the list and epilepsy, specifically temporal lobe epilepsy (TLE). Of course, all possibilities have to be explored for a differential diagnosis, but TLE fits with her symptoms: SYMPTOMS OF TEMPORAL LOBE EPILEPSY: Sensations such as déjà vu (a feeling of familiarity), jamais vu (a feeling of unfamiliarity) Amnesia; or a single memory or set of memories A sudden sense of unprovoked fear and anxiety Nausea Auditory, visual, olfactory, gustatory, or tactile hallucinations. Visual distortions such as macropsia and micropsia (Alice in Wonderland hallucinations in which things appear larger or smaller than they are in reality) Dissociation or derealisation Synesthesia (stimulation of one sense experienced in a second sense) may transpire. Dysphoric or euphoric feelings, fear, anger, and other emotions may also occur. Often, the patient cannot describe the sensations. Olfactory hallucinations often seem indescribable to patients beyond "pleasant" or "unpleasant". 1 WHAT CAUSES SEIZURES? There’s a wide variety of etiology for seizures: traumatic brain injury (maybe Susan did have a concussion after all), infections like meningitis (common in freshmen), stroke, brain tumors, blood vessel malformations, genetic syndromes, and childhood trauma (AHA!). THE BODY KEEPS THE SCORE Research shows that childhood abuse has enduring negative effects on brain development. In a groundbreaking book, The Body Keeps the Score, author Bessel van der Kolk pulls together research and years of practice to make the case for the complex impact childhood trauma has on the mind, body and spirit.2 Physical, sexual and psychological trauma in childhood may lead to psychiatric difficulties that show up much later. Anger, shame and despair can also be directed inwards, resulting in depression, anxiety, impulsivity, delinquency and substance abuse. Recent research into the impact of childhood trauma on the brain focuses on the limbic system. In the popular movie Inside Out, the audience gets to see cartoon characters acting out the various emotions of a pubescent girl. This film does a great job of showing what the limbic system does. The limbic system lies deep to the cerebrum and includes the hypothalamus, the hippocampus and the amygdala. It supports a variety of functions including emotion, behavior, motivation, long term memory and olfaction. Recent research points to brain abnormalities associated with childhood abuse including limbic irritability, manifested by increased symptoms suggestive of temporal lobe epilepsy, and an increased incidence of clinically significant EEG abnormalities.1,2 TLE is difficult to diagnose because its symptoms mimic those of other psychiatric and non-psychiatric illnesses. Common psychiatric disorders associated with childhood trauma are a somatoform disorder (patients experience complaints with no discernible medical cause), panic disorder with agoraphobia (fear of open spaces), borderline personality disorder and dissociative identity disorder (formerly called multiple personality disorder). PTSD has also been linked to childhood trauma, in which people re-experience the traumatic event in waking life or in dreams.1 The characteristic electrical discharge of TLE is observed with an EEG during a seizure. The authors of a recent study have developed a Limbic System Checklist (LSC-33) which calibrates the frequency with which patients experience symptoms of TLE. I've included a presentation that shows the LSCL-33 and included the first page of the tool so you can see what it looks like.3 In patients who acknowledge both physical and sexual abuse, the average score on the LSC-33 is 113% greater than patients reporting no abuse.4 SUSAN’S CASE In Susan’s case, the EEG was positive for TLE. Her lab results were normal and there was no sign of brain trauma or tumor with CT or MRI. Upon further discussion with Susan, it was discovered that she had suffered several years of physical and sexual abuse by her stepfather. The good news is that there is treatment available for TLE induced by childhood trauma. Though more severe forms of epilepsy can require medication and/or surgery, psychotherapy has been shown to alleviate TLE symptoms in those with childhood trauma. I’ve written about treatments for childhood trauma in two other articles: Keep What You Love, Return the Rest: Healing from Trauma with EMDR https://allnurses.com/keep-what-you-love-return-t663711/?tab=comments#comment-6947680 EMDR: Another Tool for Your Mental Health Toolbox: https://allnurses.com/emdr-another-tool-your-mental-t665133/?tab=comments#comment-6962360 PART 2 I hope you’ll check back in on my blog and read part 2. I’m going to discuss the specific impact of childhood trauma on the amygdala and hippocampus as well as the Adverse Childhood Events (ACEs) Study. I will also cover some innovative new treatments like the use of psilocybin to treat PTSD. REFERENCES 1. Wounds That Time Won’t Heal: The Neurobiology Of Childhood Abuse: http://www.dana.org/Cerebrum/2000/Wounds_That_Time_Won’t_Heal__The_Neurobiology_of_Child_Abuse/ 2. Van der Kolk, B. (2015). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books. 3. Reference for attached image, which is only part of the LSCL-33 (You can view the entire LSCL-33 in this pdf starting on on page37):https://drteicher.files.wordpress.com/2011/06/nesttd_keynote_post-key1.pdf 4. Teicher, M. H., Gold, C. A., Surrey, J. & Swett, C. (1993). Early childhood abuse and limbic system ratings in adult pyschiatric outpatients. Journal of Neuropsychiatry and Clinical Neuroscience, 5(3), 301-6.
  2. WHAT DOES THE RESEARCH SAY? Google “How to pass the NCLEX-RN the first time” and you’ll get many results, some of them more reliable than others. You’ve learned in nursing school that it’s important to look for evidence-based resources, so I thought I’d back up my NCLEX success tips with hard facts. Evidence for educational strategies that support NCLEX success is rare, but there are some studies out there with interventions that correlate with NCLEX success. Success on the NCLEX-RN actually starts before admission to nursing school. Studies have shown that pre-admission scores on reading and math assessments, pre-clinical GPA and scores on the NLN-PAX-RN are all predictors of NCLEX success.1, 2 Several studies stressed the importance of setting up a test preparation plan and sticking to it. A few hours each day of nonnegotiable study time is crucial. Put it on your calendar.2, 3 A qualitative study asked nursing students what they thought contributed to their first-time success on the NCLEX-RN. She interviewed 12 students and grouped their responses into four categories: 1) practicing NCLEX-RN questions; 2) nurse clinical experiences; 3) receiving support; 4) participating in an NCLEX-RN review course.4 Another study was an evidence-based education project with BSN students. They provided students with coaching, test-taking strategies, study groups, review courses, review books, self-assessment, as well as time management, relaxation and anxiety reduction techniques.3 There are many comprehensive exams that mimic the NCLEX (Often called RN-CAT): Mosby, NLN, HESI, ATI all assess preparedness. There is a correlation between scores on standardized exam like HESI or ATI and passing the NCLEX. 1 NCLEX-RN FORMAT Multiple studies mentioned the importance of understanding the test format, so let’s review1, 4: You will have between 75-265, and that includes non-scored experimental items. You will also have 6 hours. As I am sure you know by now, the test is adaptive and the length of the exam and the specific test items depend on the candidate’s knowledge level and ability. If you get one right, a more difficult item is next. If you get one incorrect, an easier item is next. The test is scored with something called a logit, a unit of measure used to calibrate items. It is a prediction of the probability of an event. The higher a person’s ability relative to the difficulty of an item, the higher the probability of a correct response. This means the computer can make a pass/fail decision with 95% confidence. The idea is to determine at what point the candidate is answering items correctly about half the time. After item 75, the computer calculates the standard error to estimate candidate competence. If it’s at or above competency, the computer shuts off. If it’s below, the computer shuts off. It only keeps going if more items are needed for a statistically significant measurement. Two things can happen to cause the computer to use the last 60 items to estimate your score: you reach 265 questions, or time runs out.2 HOW TO FAIL Students who failed the NCLEX-RN the first time, identified inadequate study habits, lack of knowledge about how to prepare for the exam, difficulty setting priorities and poor test-taking skills. Students felt most prepared for patient priorities and delegation and least prepared for maternity/newborn, pediatrics and pharmacology.1 There are some factors beyond your control. If you are a student who is experiencing English as a second language, if you have educational deficits, a low preclinical GPA or test anxiety, studies show you are more likely to fail the NCLEX-RN.1,2 In addition, there is a strong relationship between a delay of more than 3 months post-graduation before taking the NCLEX-RN and failing.1 PRACTICE, PRACTICE, PRACTICE I know you’ve heard this so many times from your professors and your friends, but it’s true. The more questions you do, they better you’ll do on the exam. It’s important to understand question structure and use practice questions to prepare. Practice questions force you to analyze the stem and understand what the question is asking. You’ll improve if your practice questions have the rationale for content and for incorrect answers. SAMPLE QUESTIONS ONE A client had an IV started at 0900. At 0930 the client rings to complain of shortness of breath. The client has a blood pressure of 90/60 mm Hg from a baseline of 130/82 mmHg, and a pulse of 110 beats per minute. Which of the following should the nurse do FIRST? Check the IV tubing for air bubbles Assess the IV tubing for loose connections Clamp the tubing and turn the client on the left side Raise the head of the bed Rationale: This client is showing signs of air embolism, which is a complication of Intravenous therapy. When a client complains of shortness of breath, there is a need for immediate intervention, and no further assessment is required. The correct interventions for air embolism include: clamping the tubing, turning the client on the left side with the head of the bed lowered to Trendelenburg to trap the air in the right atrium, assessing vital signs and breath sounds, administering oxygen and notifying the HCP. Complications of air embolism include shock and death. Options 1 & 2) Checking for air bubbles and loose connections are correct prevention activities, but do not address the presence of a presumptive air bubble already in the client’s bloodstream. Option 4) Raising the head of the bed may cause the air embolism to migrate to the lungs or brain. The correct answer is option 3 Competency: Pharmacological and Parenteral Therapies, IV Therapy Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 291 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1510 TWO A nurse on an oncology unit receives verbal report about four patients. Which client will the nurse see FIRST? A client with a total serum calcium level of 10.8 mg/dL, complaining of fatigue and nausea. A client with a temperature of 100.1 oF and a neutrophil count of 950 neutrophils/mcL A client with lymphoma who has shortness of breath, edema of the neck and arms and difficulty swallowing. A client with metastatic breast cancer, complaining of throbbing and aching joint pain and a platelet count of 50,000/mm3. Rationale: 1 & 3 are oncologic emergencies, however, option one indicates hypercalcemia, which is potentially life-threatening metabolic abnormality resulting from calcium release from the bones exceeding the ability of the kidneys to excrete calcium. Symptoms include serum calcium above 10.1, fatigue, weakness, confusion, polyuria, nausea and vomiting. Answer option three is a true oncologic emergency that can progress to cerebral anoxia, bronchial obstruction and death. Signs and symptoms of Superior Vena Cava Syndrome (SVCS) include dyspnea, edema of neck, arms, hands, skin tightness, difficulty swallowing, distended jugular veins and increased ICP. SVCS is associated with a diagnosis of lung cancer and lymphoma. It Option two indicates a client who may be developing neutropenic fever, which is associated with any temperature of 100.4oF and a neutrophil count of <1000 neutrophils/mcL. This client has the potential for developing an emergency but is not a priority. Option four indicates probable pain from bone metastasis. It is important to treat pain, but it would not be the priority. The platelet count is low, but not low enough to be associated with spontaneous bleeding (<20,000/mm3). The correct answer is option 3 Competency: Management of Care, Establishing Priorities, Oncology, Evaluation Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pgs 372, 377, 382 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1482 THREE The nurse is assessing a client for the possibility of pregnancy. Which of the following statements by the client indicate probable signs of pregnancy? Select all that apply. “I’ve been nauseated every morning and I haven’t had a period in two months.” “I’m just so tired all the time.” “I took a pregnancy test and it came up positive.” “My breasts are much larger, and my nipples are sore.” “I’ve been having irregular contractions.” “My boyfriend felt the baby moving.” Rationale: Options 3 & 5) are probable signs of pregnancy. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they are still not 100% reliable in confirming pregnancy. Options 1, 2 & 4) are presumptive signs of pregnancy. These are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy. Amenorrhea can be caused by early menopause, endocrine dysfunction, malnutrition, anemia, diabetes mellitus, long-distance running, cancer or stress. Nausea can be caused by gastrointestinal disorders. Fatigue can be caused by anemia, stress or viral infections. Breast tenderness can be caused by chronic cystic mastitis, premenstrual changes or use of oral contraceptives. Option 6) Palpating for fetal movements is a positive sign of pregnancy when performed by an experienced healthcare provider. Fetal movements that have not been confirmed by an experienced practitioner are considered presumptive signs. The correct answer: options 3 & 5 Competency: Health Promotion and Maintenance, Health screening, Antepartum, Assessment Ricci, S. S., Kyle, T. K., & Carman, S. (2017). Maternity and Pediatric Nursing (3rded.). Philadelphia, PA: Wolters Kluwer. 363-364 Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1665 FOUR The nurse has been teaching a client about a new prescription for carbamazepine (Tegretol) for tonic-clonic seizures. Which of the following statements by the client indicates need for further teaching? “I should call the doctor if I notice a rash or blurry vision.” “If I experience nausea or blurry vision, I should stop taking the medication immediately.” “I need to take the medication with food, but not with grapefruit juice.” “I need to take the medication twice daily at the same time each day.” Rationale: Option 1) Toxic effects of carbamazepine include severe skin rash, blood dyscrasias and hepatitis. Visual disturbances and serious skin reactions should be reported. Option 2) Client education about carbamazepine includes teaching that medications should not be discontinued, even if adverse side effects occur such as rash, dizziness, nausea or blurry vision; however the healthcare provider should be called if there are adverse side effects. Option 3: Giving medication with meals can reduce the risk of GI distress, however grapefruit juice may increase absorption. Option 4): Strict maintenance of drug therapy is essential for seizure control. The correct answer is option 2 Competency: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions, Evaluation Hodgson, B. B. & Kizior, R. J. (2014). Nursing Drug Handbook. St. Louis, MO: Elsevier. Pgs 180-182 Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14thed.). Philadelphia, PA: Wolters Kluwer. Pg. 2000 FINAL ADVICE Take advantage of end of program review options. The NCSBN offers an online review course of 3, 6 or 9 weeks – the candidate has 24/7 access to material. Since the NCSBN is the organization that “writes” the NCLEX, I think this would be the one to take if you had to pick just one.5 The most important thing you can do to increase your chances of passing the NCLEX-RN is to accept responsibility for your success. For more tips and tricks, check out another article I wrote – it will lead you through strategies for understanding the stem and choosing the correct answer option: Are You Ready for NCLEX? Think PATIENT SAFETY and You Will Be! REFERENCES Higgins, B. (2005). Strategies for lowering attrition rates and raising NCLEX-RN pass rates. Journal of Nursing Education, 44(12), 541-7. Lavin, J. & Rosario-Sim, M. (2013). Understanding the NCLEX: How to increase success on the revised 2012 examination. Nursing Education Perspectives, 34(3), 196-198. Bonis, S., Taft, L. & Wendler, M. C. (2007). Strategies to promote success on the NCLEX-RN. An evidence-based approach using the ACE Start Model of knowledge transformation. Nursing Education Perspectives, 28(2), 82-87. Blazen, B. B. (2008). The road to NCLEX-RN Success. The Journal of the New York State Nurses Association, 45(2), 5-12. https://www.ncsbn.org/4762.htm
  3. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    I should have posted this in the article - evidence for improved patient outcomes when cared for by a BSN: "hospitals in Pennsylvania had “a substantial survival advantage” if they were treated in hospitals with higher proportions of BSN-prepared nurses. That groundbreaking study, published in the Journal of the American Medical Association, found that a 10-percent increase in the number BSN-prepared nurses reduced the likelihood of patient death by 5 percent. The link between nurse education and patient outcomes was confirmed in 2011, when Aiken published a study in Medical Care that found that a 10 percent increase in the proportion of BSN-prepared nurses reduced the risk of death by 5 percent. In 2013, Aiken co-authored a study in Health Affairs that found that hospitals that hired more BSN-prepared nurses between 1999 and 2006 experienced greater declines in mortality than hospitals that did not add more BSN-prepared nurses. “We’ve established this association over and over again,” she said. “If hospitals really want to improve care, they should hire more nurses with bachelor’s degrees.” https://www.rwjf.org/en/library/articles-and-news/2014/04/building-the-case-for-more-highly-educated-nurses.html
  4. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    I erroneously reported that 54% of nurses who responded to my article stated they had never made an error - but I should have said they stated they had never made an error that harmed a patient. Do you have any solutions for how to promote patient safety other than joining the ANA?
  5. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    Thank you so much for pointing out my mistake.
  6. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    I completely agree - and as a new instructor I have to be very careful how much I criticize the status quo. It is my passion to move nursing education forward so that what we teach students is more closely related to reality. I also think the culture of nursing gets us into bad habits. I hate that there are seasoned nurses who make newer nurses feel "dumb" for doing the right thing (not to mention patients doing it as well - I never even thought of that!). I try to warn my students ahead of time that this may happen, but it's so frustrating. I really appreciate your comment.
  7. SafetyNurse1968

    Is It Possible to Never Make an Error? The Perfect Nurse Fallacy

    Thank you so much for reading and commenting. I agree that hands on practice is a severe limitation for nursing students these days. It is becoming more and more difficult to find facilities who will allow students to come and learn how to be nurses. Even when we can find facilities, students are often very limited in what they are allowed to do. Many places don't allow students to even pass medications any longer. The point I am trying to make in the article is that though nurses are ultimately responsible for patient safety - you are so correct - we are the last line of defense, medication administration is complex and that considering other options and ideas for supporting safety is important. Outcomes that are improved by having BSNs and MSNs are the bedside include decreased patient mortality (which may or may not be caused by med error - that statistic is not available), decreased hospital stay, and reduced readmission rates. I agree that we must be held accountable, I also think that institutions pass the buck to nurses. It's a fine line, and a tough one to balance. I am advocating for nurses to understand that admitting to error is the first step towards preventing it in the future, and that we shouldn't be penalized for admitting that we have made mistakes.
  8. Mistakes Were Made Is it possible to get through an entire nursing career without making a mistake? If nurses are well-trained and careful, can we prevent patient harm? What does it take to get through a hectic nursing shift without making an error? These are the questions that motivate me as an educator and a nurse researcher. I wrote an article a while back talking about how nurses, despite our best efforts, make mistakes that sometimes lead to patient harm (Why Do We Continue to Harm Patients?) At the end of the article I gave a survey asking how many of my readers had made errors. Of the 39 folks who voted, 54% of you said you had never made an error. Compare that to the 18% who weren’t sure. I’m going to make an argument that more mistakes and errors occur than you think by asking another question, how do we know an error has been made? The most common way healthcare organizations track error is through self-report, which is voluntary. We have to know we’ve made a mistake, be willing to report it, know how to report it, have time to report it and feel safe enough to report it before anyone finds out we’ve made an error. That’s a lot to ask for nurses who are often overworked, underpaid and who have zero job security. The evidence suggests we make many more errors than are reported. In one study, over a four-day period, pharmacists, RNs, LPNs and pharmacy technicians directly observed 2556 doses of medication administration in 36 hospitals across the US. They observed 300 errors (11.7%). An in-depth chart review over that same four-day period detected 17 errors (0.7%). And incident reports? You guessed it - there was 1 – giving an error rate of 0.4%.1In another study clinical evidence from 6 different direct observation studies was reviewed, and the differences were even more startling: “true” error detected by direct observation was 65.6%. Chart review yielded an error rate of 3.7%. Self-report gave an error rate of 0.2%.2 Fundamentals I recently taught fundamentals of nursing to some brand-new BSN students. They had to do a simulated medication pass, and I used a checklist to grade them. It looked something like this: My students struggled with performing the three checks each and every time. (I added that they also needed to check the expiration date, something else they couldn’t seem to remember). I know nerves get in the way, and I was supportive and gave cues when needed, because at their level, cues are needed. We only expect a student nurse who is about to graduate to be able to do a med pass correctly, perfectly, every single time. What inspired me to write this article was the experience my newbies had at the clinical site. After 10 weeks in the sim-lab, struggling to learn the basics of nursing care, things like bed making, bed baths, head to toe assessment, medication administration, they finally got to go to an actual facility and observe RNs, LPNs, and CNAs do the real job of direct patient care. They were incredibly nervous about talking to a patient for the first time, so worried they would make a mistake, say the wrong thing, mess up.At the end of the first day, we met for post-conference and some faces were shining with joy, I kid you not, at the realization that I can do this!There were also some hushed conversations about the reality of nursing. See if any of these quotes look or feel familiar: “She didn’t tell the patient what any of the meds were for.” “None of them do the three checks.” “My nurse didn’t even check the patient’s arm-band.” “She gave the wrong dose of insulin, and she realized it afterwards, but I never saw her tell the patient or fill out an error report. I could tell she felt really embarrassed.” What Are We Teaching Kids These Days? Do you remember in nursing school when they taught us about medication administration? Here’s a list of what we are supposed to know about each and every medication (and I am sure I have missed a few): Generic vs. trade Classifications Forms Pharmacokinetics Therapeutic vs. side effects Allergies Interactions Timing (peak, trough) Common schedules (AC, STAT) Route Method of measurement Interdisciplinary (pharmacy, prescriber) Types of orders (standing, PRN) Distribution systems Back in 2004, when I was a student, they were still doing five rights: dose, patient, drug, time and route. I did a little research and discovered that the five rights were first seen in The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities,1893.3 Since then, the number of rights has increased, one school even has 12! Some of those additional rights include things like documentation, client education, response, right to refuse. Do you remember how we were taught to check all the rights three times? The three checks: Check 1: when medications are pulled from where they are stored (med drawer, dispensing machine/Pyxis); Check 2: when preparing the medications for administration; Check 3: at the patient’s bedside. I have three problems with this whole set up: 1) there’s no evidence to support this methodology; 2) it places all of the responsibility for patient safety on the nurse; 3) it only works if you do it, and we aren’t doing it. Our responsibility is to administer medication as prescribed while preventing error and patient harm(that’s straight from a Fundamentals texbook4) yet the error rate hasn’t changed.5 We are the last line of defense – physicians and advanced care practitioners prescribe medications, pharmacists fill the prescription, and the nurse gives the medication. As we go through our daily routine of checking and re-checking, nurses prevent up to 70% of prescribing and dispensing errors before they reach the patient.6 We prevent error by intervening when we see a medication order that doesn’t make sense, or identifying an allergy that was missed, or investigating with the patient and family to discover a previous medication issue not found upon initial assessment. Despite our best efforts, nurses may commit between 26% and 38% of medication errors.6In a 2010 survey, 78% nurses admitted to making a medication error, and these are just the ones they were aware of.7 The Fallacy Of The Careless Nurse Some folks who read an article highlighting the nurses’ role in patient harm get angry, and I don’t blame them. Nurses are often vilified for errors that reach the patient. Nurses are at the sharp end of the stick – we are the last stop for safety. When things go wrong, we are often blamed. Yes, there are instances of bad nurses who do bad things. There are incompetent and careless nurses. There are nurses who don’t care. But I believe they are few and far between. What I am suggesting, is that it isn’t always our fault. I’m suggesting that healthcare systems are error-prone places. I’m suggesting that no matter what we do, errors will occur. Healthcare is just too complex. The odds are stacked against us. Statistics show that more than one error occurs per patient per hospital day.8I don’t believe there are that many careless nurses out there. I believe the system is deeply flawed. The culture of nursing is such that many of us are unwilling to even consider that we have made an error. And as you can see, we continue to teach our nursing students that just being carefulwill somehow magically protect them from making a mistake. What To Do? Nurses appear to believe that they should be capable of administering medications without errors, regardless of the external circumstances. When you ask nurses about error, we typically believe it’s all our fault. In 2003, 779 nurses were polled, and 79% agreed that medication errors occur when a nurse carelessly neglects to follow the 5 rights. 958% believed that the commission of a medication error was indicative of nursing incompetence. In 2008 the same poll was conducted, and those numbers have only increased.10This study highlights that negative opinions and individual blame continue to be associated with error making. In the article I wrote about the role of nurses in error, I asked you for solutions and here is a list of your answers: Staffing (over 50% of those who commented on my article suggested that staffing is at the root of the role nurses play in medication error.) Incentives and benefits for senior, experienced nurses to stay at the bedside Barcode medication administration Electronic charting Improving critical thinking Prioritizing patient needs Nurses are understaffed and overworked, caring for sicker patients in greater amounts with less support, experience and training Total overhaul of BSN programs Keep your head down, keep quiet and stay employed Personal Safety Checklist I agree with your ideas, but I’m not sure how to get them implemented, other than to tell you to go work at a magnet hospital in a state with safe staffing laws. I’m working very hard on improving critical thinking in my nursing students, but from the perspective of a BSN instructor, I can tell you a total overhaul isn’t on the horizon. I want you to know there are a few things we can do to safeguard our patients and our license. As a Certified Patient Safety Professional, a long-time nurse educator, a nurse who practices at the bedside, and former patient safety officer, I recommend nurses use the following checklist for personal safety measures. Anything you can complete from the following list has evidence behind it to support improved patient safety. As nurses, keeping patients free from harm is our goal, so why not pick one and get it checked off? Education: BSN, MSN (patients cared for by nurses with higher degrees have better outcomes) Nurse led research (nurses at the bedside are the best folks to initiate research that will make a difference in patient safety) Certification (patients cared for by certified nurses have better outcomes) Self-care (nurses who are stressed out and fatigued are more likely to make an error) Ongoing training – look for the following components in your continuing education: High quality CE (The ANA has some great free CE, and so do I!) Simulation (So many studies show a positive relationship between high-fidelity simulation and improved patient outcomes) Patient safety focus Charting (Chart everything. Chart everything. Chart everything – for your safety as well as your patients’). Use of checklists whenever possible (research shows use of checklists reduces error) Speak up! Join the ANA and contribute to the Political Action Coalition today! If every nurse gave $1, we would have $3 million dollars to fund lobbying efforts to get safe staffing laws passed in all states. If we do nothing, nothing will change.11 End Note Here’s one final item I have removed from the checklist because it isn’t a goal, though it is most likely a certainty in your life. The odds that a nurse will make it through a career without making a mistake are close to zero. Previous involvement in error (nurses who have made errors that they recognize and take responsibility for are less likely to make them in the future) I wrote a story about a wonderful, well-trained, careful nurse who made a mistake that harmed a p.html), and I encourage to you read it. It inspired me and I hope it inspires you as well. We must admit to and report error. If we don’t, we can’t know what problems need to be fixed. For more information on how organizations can improve, please read: This Nurse Quit, Will You? What to look for in an organization. REFERENCES 1. Barker, K., Flynn, E., Pepper, G., Bates, D., & Mikeal, R. (2002). Medication errors observed in 36 healthcare facilities. Archives of Internal Medicine, 162(16), 1897-1903. 2. Kiekkas, P., Karga, M., Lemonidou, C., Aretha, D., & Karanikolas, M. (2011). Medication errors in critically ill adults: A review of direct observation evidence.(report). American Journal of Critical Care, 20(1), 36-44. 3. Wall, B. (2001). Definite lines of influence: Catholic sisters and nurse training schools.Nursing Research, 50(5), 314-321. 4. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016).Fundamentals of nursing (9thed.). Philadelphia, PA: Elsevier. 5. Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Phil, M., Goldmann, D. A., & Sharek, P. J. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363(22), 2124-2134. 6. Bates, D. W. (2007). Preventing medication errors: A summary. American Journal of Health-System Pharmacy, 64(14), S3-S9. doi:10.2146/ajhp070190 7. Jones, J. H., & Treiber, L. (2010). When the 5 rights go wrong: Medication errors from the nursing perspective. Journal of Nursing Care Quality, 25(3), 240-247. 8. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41. 9. Cohen, H., Robinson, E. S., & Mandrack, M. (2003). Getting to the root of medication errors. Nursing, 33(9), 36-46. 10. Cohen, H., & Shastay, A. D. (2008). Getting to the root of medication errors: survey report. Nursing, 38(12), 39-47. 11. https://www.nursingworld.org/practice-policy/advocacy/
  9. SafetyNurse1968

    Are Patients Cared for Equally? Challenges of the VIP Patient

    I will never forget the elderly russian lady we took care of on my unit. She had been on a flight to the US from somewhere in Russia when she had a massive stroke. The nearest place to land was our neck of the woods, and somehow (you know how bed control works!) she ended up on the oncology unit. She never regained consciousness. We knew her name of course (passport), but were unable to locate any relatives. She lived for another three weeks as we provided care to this woman with an unknown past. Oncology nurses know how to send someone out in style - she was comfortable and loved. I spent many hours talking with her, trying out some of my broken Russian from back in college when I stumbled through a year of course work in that lovely language (Xorosho!). She was the opposite of a VIP, yet I recall the CEO coming for a visit to ensure she was receiving excellent care. A local celebrity preacher used to come stay with us at times as well, but he never asked for VIP status - he just wanted to remain anonymous, and we certainly kept it that way. In the end, they both passed on.
  10. SafetyNurse1968

    Welcome Home!!!! - Home Sweet Home

    I watched both videos, but still can't figure out how to post an article. Feeling like a ding dong! Thanks, Safety Nurse
  11. SafetyNurse1968

    Are We Letting Our Patients Suffer?

    I'm so glad someone has the courage to talk about the other side of the war on opioids. I'm teaching patient centered care to brand new nursing students, and these new laws on pain medications violate everything we are teaching new nurses: treat the patient, pain is what the patient says it is. I know we are trying to find alternatives to opioids, but it can be very difficult to do patient centered care in the face of these new laws. The stories ya'll have posted are heart breaking. We have to advocate for our profession. Join the ANA, donate to the PAC and speak out. It's great to see your voices here on allnurses.com, but we MUST speak up in public and political forums if we want things to change. Only 3% of nurses are politically active. Imagine what we could accomplish if it were 90%?
  12. I sat down with Margo in her dining room one evening to talk about a medication error she made when she was a new nurse. I asked Margo to tell me a bit about herself. She hadn't always wanted to be a nurse. She was studying entomology (bugs) at NC State, when the forest service instituted a hiring freeze, so she switched her interest to nursing. We talked a bit about the oncology unit where she was hired as a new nurse - we share a bond because I was a baby nurse on the same unit and some of the same nurses who trained me are still there! Below are excerpts from our conversation - to get the full interview, listen to the podcast (link is at end of article). I have put all of Margo's comments in italics. SN: Tell me about the error... Margo: I was 4-6 months into my career as an RN, and had finished a 3-month long orientation as a new graduate but was still feeling overwhelmed. The med error started with an accidental duplication of an insulin order. 44 units of Lantus was ordered for bedtime, but there was also an order for 44 units of regular insulin. I remember flipping through the order and thinking that it didn't look right, I was still feeling overwhelmed, and it's embarrassing to admit, I wasn't familiar enough with insulin to verbalize to myself why I thought it was wrong. I just remember I knew something was off. I had great support from my peers, but I was always asking questions - and I was trying so hard to practice independently. I fell into a trap with nurses who make med errors in that I became task focused. That's what we teach in nursing schools. We teach tasks because it is so easy to teach and evaluate. In our orientation program, we don't teach nurses how to precept other nurses, and we don't teach nurses how to think critically. In my mind, I knew something was wrong, but I had to get through the night, and I totally relied on the computer and the system. I remember thinking, there is no way this can be in the computer and be wrong. The NP wrote this order, a pharmacist reviewed it, another nurse checked it...wouldn't the computer catch it? I went to pull the insulin from the pyxis knowing something was wrong, but still unable to say why. And I know I shouldn't have given it at all if I couldn't say why it was wrong. I was task oriented and not thought oriented. I pulled up the lantus, and then I went to pull up the 44 units of regular insulin and I remember thinking, this is the part where the pyxis will stop me, but it didn't. I walked in the patient room and said, "I have your 44 units of Lantus and 44 units of regular insulin - is this what you do at home?" The patient said yes, but who knows why - maybe he was poorly educated, maybe he didn't feel empowered. I wasn't skilled enough to ask open-ended questions, instead, I asked for confirmation. I should have asked, "tell me about your home med regimen" instead of asking a yes or no question. So he confirmed, and I gave him the large dose, still knowing something was wrong. Part of my reasoning was his previous dosing - he got large meal boluses during the day, and on an oncology unit, we give big doses of insulin to people on high dose steroids. I remember trying to justify it... I walked past his room about 4 hours after giving the medication. His light was still on, he was laying contorted position, he was unresponsive, seizing and incontinent. I called for assistance, and the charge nurse called a code blue immediately. I remember saying over and over, get a glucometer, it's his glucose. We got a reading and it was 12. He pulled out his IV while seizing and we had to put in a new one. He was minutes away from him dying or losing all brain function. I had to admit in that moment what happened to save his life. I had to scream "his blood sugar is low, because I gave him too much insulin" while everyone was running around in a panic trying to resuscitate him. There was no hiding it - pride could have killed him. I hope I never harm someone like that again. I pushed dextrose all night, and the next day there was no discernable loss of function. SN: Margo let me know she shares this story with coworkers and with all the nurses she precepts. She wants to emphasize the importance of owning and reporting mistakes, but also of knowing you can recover from an error- it is survivable. Margo: I don't think every nurse will harm someone, but you can't tell me there is a single nurse out there who hasn't made some kind of error. SN: Margo said she got excellent support from her unit, her manager and the hospital. She was referred to the Employee Assistance Network, but she said after her first Root Cause Analysis session, she felt like that was enough therapy. We talked briefly about the new RCA guidelines that recommend not including the person who made the error, and she is strongly opposed. Margo: Being involved in that RCA process kept me in nursing. Without it, I wouldn't have recovered from this at all. It was a healing experience for me. RCA helps you realize it's not just you, it's also the system. I got to weigh in on "what will we do next so it doesn't happen again" and I got to design the changes to the programming so it would fix the problem. It was a group of people who supported me and we stood together - we were able to say, "this is what we made so no one has to go through this again" I asked Margo for tips on how not to make an error Margo: In nursing school, they treat error as something really rare - the Quaid twins with the heparin, the antibiotic being given through the epidural, and the tube feeding hooked up to the IV - sensational cases - so you think, that's what a med error is. I would never do that! I'm a careful person. We need to teach nurses, you WILL make mistakes. I was precepting a new nurse, and we were talking about med errors, and she said something like, "well I would never do that, not me" and I said, "Well I have. I hurt someone very badly" She looked at me like, "why are you telling me this" I said, "I hope you never hurt anyone - what is important is to recognize that when you do make an error, you can recover, you can still be here." Safety Rules! Podcast is on stitcher, if you don't like iTunes Links (what you'll be clicking on if you hit the hotlinks above): iTunes: Safety Rules by Kristi Miller, RN, PhD, CPPS, HNB-BC on Apple Podcasts Stitcher:Safety Rules | Listen via Stitcher Radio On Demand