BonnieSc

Got it--it's been years since I did paper medication documentation except in downtime (when there's not a lot of oversight)--I thought the OP was talking about her brain sheet. I can see both how the documentation could be confusing to others and how it would keep me from second-guessing myself. Ideally I think the medication system would be designed so that the prescription specified "half tab" or "two 325 mg pills", as a reminder to everyone, but that isn't possible in all settings.

I've responded to this many times (and it's fine if others don't agree, but this is misrepresenting what I say, though I can't think how I could say it more clearly to be honest)--of course documentation is vital to medication administration, but it is vital to EVERYTHING we do. It is, as I said and you quoted, not "specific to medication safety". Why add another "Right" to medication safety when we have to do it for all of our actions? The purpose of the Five Rights, as I see it, is to add doublechecks for MEDICATION. I can see adding "right rate" to the Five Rights, and I do teach this as an additional right for IV medications, because that is specific to medication safety. As others have pointed out, the more "Rights" that are added, the less likely nurses are to comply with any of them at all.

Why is that incorrect? Just yesterday I was giving a training regarding medication error and told the participants (actually I am training them to give the seminar themselves) that I want people to feel empowered to find their own personal safety mechanisms, as well as help develop a safe system hospital-wide. What works for one person doesn't for another. Some people think it's odd when I ask them to check very simple math for calculations, but I know what I need.

Thanks but it is the local nurses who are really awesome! You raise an interesting point--we really are trying to do the same thing with much less. Sometimes I wonder if that's the best idea, because it's generally going to end in failure. But if we wait to do full ACLS until we have all the right equipment, it may simply never happen.

Wow, special thanks to the editor for making this appear organized and readable with the text breaks and headings. I hadn't realized it was so long when I wrote it. I hope people actually read/skim to the end, and that it is interesting and useful!

Anatomy of a Code I just left a code blue, a very successful one. Yes, the patient died; he never had a rhythm. But a list of the learning experiences we had this morning would cover two pages. At the beginning of the debrief, I thanked the patient for giving us this gift. Where I work.... I work in a developing country in East Africa (not naming the country for anonymity's sake). But I don't work in a refugee camp or a primitive cinderblock hospital like those I used to see in the news; I work at one of the better-equipped hospitals in the region. When I first arrived a year ago, I doubted whether I was really needed, whether I shouldn't be somewhere where the need is more desperate. But not only has this hospital demonstrated some real gaps that I have tried to help with (it might be the best, but it is very far from a western hospital), but we are a beacon for the rest of the country, a small microcosm showing what might be accomplished with more staff, more supplies, more water and electricity. Cardiac Arrest The code blue, or "resuscitation", as we call it here, started the same way they do in the US: a patient's relative came out and said the patient wasn't breathing. I found out about it the same way I do at home: someone called for the crash cart (or "emergency trolley"). I left my office and went to see what was happening. I saw someone giving chest compressions without gloves on, so I put on gloves and took over. Getting Started There's no overhead paging system. Someone ran to the ICU and the nurse manager and charge nurse came over to be the code blue team. Doctors got wind of the situation and came in. The nursing students came in the room but hung back. My nursing students this week are experienced nurses with high school educations, in the process of continuing their educations to get a nursing diploma through a bridge program. Certainly they had seen many patients die, and perhaps had even attempted resuscitation, but they never had seen a coordinated effort with this kind of equipment. Teamwork What went well? Teamwork. The nurses looked for unmet needs and moved quickly. When I participated in a resuscitation earlier in the year, it was chaos; some things happening, other things not. Mostly, I have been frustrated by how slowly the staff often moves in cases that seem urgent to me. Later someone might explain to me that no one moved fast because they considered it a lost cause. The nurse manager and I have been trying to change that way of thinking. Compressions also went pretty well. It has been hard to train people in CPR without enough dummies; often for our CPR classes (taught by a local nurse; I'm just there to help with a practice station) we have three dummies for thirty people. But I saw that with some coaching, the staff is now pushing hard and fast. We just have to work on placement. There is a perception that compressions should be done over the heart instead of on the sternum. When you do CPR in a different language, there are some surprises. The language of the hospital is English, but most staff are more comfortable in French, and most comfortable of all in the local language. Counting to thirty in the local language takes way too long--the number words are lengthy. Some count in French, but they are "supposed" to count in English (I couldn't care less, but that's how they're taught). Except remembering how to count to thirty in English is hard for them even when they aren't under stress; forget doing it in the middle of compressions, loudly. Typically, they count to ten three times in English, speaking under their breaths. Try being ready to give breaths in that situation! Struggles So, what were the struggles? One, and I include myself in this... those directing the action were trying to do too much. No one can do good CPR or give effective respirations if they're also trying to tell others what to do. I took myself and the ICU manager out of the patient's direct care, stopped a nurse from doing anything besides giving medications, and told the resident leading the code that he was not to be in line for CPR. I was the most experienced at BLS/ACLS, the ICU manager knows more about the contents of the crash cart and can speak the language if necessary, and the doctor needed to be free to make orders. I am used to working with an extremely efficient code blue team where everyone knows what to do and where to stand. I remember how unnecessarily perfectionist some of that seemed when we started the code blue team. The value has never been clearer. We didn't start ACLS soon enough. Epinephrine was given somewhat regularly, but otherwise, we were really doing BLS. We started with an AED and didn't switch completely to the manual defibrillator. I have probed before about why, when outcomes are just as good if not better with the AED, we still use the manual defibrillator in the US. OK, I get it now. I didn't realize how much I relied on being able to read the rhythm on the manual defibrillator. ACLS You know that ACLS algorithm that hangs off every crash cart at home? Usually I don't see anyone consult it, but we really could have used it and I definitely see its value. I asked the ICU nurse manager about the algorithm later; she told me it is posted on the bulletin board in every nurses station and then agreed that it would be better stored on the crash cart. Intubation We disagreed about intubation. I asked (in the middle of doing compressions, oops) if anesthesia was coming to intubate. I was promptly told "the priority is compressions". This is a problem I run into a lot here... the nurses and doctors receive half the message but the whole story is lost. Yes, the compressions are the priority and I'm glad they understood that, but it doesn't mean intubation is just a "nice to have". I think part of what played into that--once intubation was attempted, twenty minutes later--is that it was clear the doctors aren't very comfortable with intubation. Anesthesia wasn't available, so a medical resident tried, with some difficulty (we never made it). There were great delays in compressions while intubation was attempted. This is one of those things that the ICU nurse manager probably understood but didn't say; I was the only one who didn't know. Supplies Supplies in the crash cart were severely lacking. We didn't have enough of any of the drugs; we had few options for suction tubing. The CPR board was attached to the crash cart with zip ties and we lost valuable time waiting to get it placed (no CPR button on the bed, of course). And when the first dose of epinephrine was given and I asked for a saline flush, I remembered immediately that we don't have that. I asked for a nurse to start drawing up flushes, and what was available was sterile water rather than normal saline. The nurse drawing up medications understood my point and began drawing up water flushes every time he drew up epinephrine, but another nurse might not have. And several people told me it was unnecessary because the patient had a running IV. Because flushing isn't common practice in any case, there isn't a great understanding of how fast a flush moves versus an open IV. Outcome The doctor called the patient after half an hour of resuscitation. If we had known how ill he was (metastatic cancer, which wasn't what he'd been admitted for), we might have stopped sooner, but we never had a chance to talk about that. When the doctor said "Okay, we are stopping," I said promptly a variation of the words I know so well: "Does everyone agree that we are ready to stop this resuscitation? Does anyone want to try anything different?" Everyone looked at me in surprise. I made quick eye contact with all of them. "We've done everything," the ICU nurse manager said, puzzled. "I know, but this is the question we ask," I said. Everyone agreed to stop. I thanked everyone and, because this is a religious country and we pray together before starting shift report every day, I asked one of the nurses to pray for us and the patient before we cleaned up. This, too, isn't the practice and was a surprise to everyone, and yet it seemed like the culturally appropriate thing to do. I wondered if in trying to make resuscitations as streamlined and western-like as possible, the staff had come to feel like their own cultural practices were not welcome or appropriate. Conclusion The resuscitation itself was a straightforward one. Nothing unusual happened; nothing we did for the patient did any good. But it was yet another situation in which I learned and grew at least as much from being here as the patients and staff benefit from my presence as a nurse educator.

That's a dosage error. Again, I'm not saying documentation isn't critical. It just isn't something you do before giving medications. If I could just get my students and the nurses I mentor to actually check the right patient, med, time, dose, and route, I might not really care about making this more complicated. Obviously nurses should use whatever works for them but my point is that the 5 Rights are a great tool as they are. Just last month I had a student try to draw up forty units of insulin instead of four, and an experienced nurse start to give a medication IM instead of IV.

Can you explain? I'm not sure I understand what you're getting at. (Not how I've heard "right documentation" explained, either.)

The trouble with this so-called sixth right is that it's done after the fact. The five rights are all done before medication administration--which is why I think it's a distraction ( and don't get me started on nurses who pre-document). We document EVERYTHING, preferably immediately after it's completed, so I don't see how it's helpful, really. (Continuing to keep an open mind but yet to see an argument I agree with.)

I'm not. As I said it depends on your practice setting, but many psych units have a morning med call, etc--compared to regular acute care where a patient can have meds at pretty much any hour, in addition to prn. Your setting may not be like that, but many are.

Thanks for pointing out the issues with barcoding--it is just there as a catch and the five rights are still very necessary. Having barcoding really makes clear how many near-misses there are! The same error with oil-based penicillin happened at my hospital. A traveler who was not familiar with im penicillin thought it was meant to be given IV because the dose was handwritten in international units (IU). The patient died. IM penicillin was routine for the staff nurses and they never would have made that error.

Absolutely--when we get comfortable, we can get careless. Even just thinking of unfamiliar meds, those are less likely to result in errors as the nurse checks and doublechecks. I really think the five rights are great as they are. Most of the other "rights" people are mentioning aren't specific to med administration, but are a part of nursing care and assessment in general. Medication really needs to be set aside as a procedure requiring special concentration. It's not that I don't do those other things, like assess the patient regarding that med's effects, or document; but I'm doing that all day long. As to why I said it may be different in psych vs acute care or ltc-- except on medical psych there are often fewer meds, and they are given at specific times. There may be a medication nurse who is able to focus more. It depends on the work environment.

I have heard of the vest but not seen it in acute care. On the other hand, my most recent permanent hospital really committed to no interruptions at the pyxis. I was impressed by what a difference that made. 3roppen: I'm sorry you dislike the notion that medication errors are inevitable; no one really likes to think that. It is, however, evidence-based. I'm glad you mention "luck," because luck is part of it. You'd be surprised how many errors are missed by the doctor, the pharmacy, and the nurse. As I mentioned above, a 0% error rate for a unit is generally considered a problem, not an achievement. The comparison isn't to traffic tickets--lots of people never get one. It would be to traffic violations, which I'd wager everyone does commit from time to time. Though I'm really talking to acute/critical care nurses here, and LTC. Your situation in psych, depending on the patient population and systems in place, may be quite different.

Actually, there are minor and major medication errors. And as I am a clinical instructor and have worked with many students, both as an instructor and a preceptor, I can tell you that in my experience students who practice the five rights are in the minority. They can all recite them, but they don't do them. I really don't think I am downplaying medication errors by stating that all nurses make them. I'm not sure if the comments stating that there is nothing humorous about medication errors, or that they should not be taken lightly, are directed at the original post or not. I don't think I or anyone else posting here has done either of those things. In practice I have seen a flippant attitude at times, similar to the quoted story about "I guess I should have my eyes checked," so maybe that is what's being referred to.

I didn't say doing documentation isn't important--I said I don't think it should be one of the five rights, or rather six rights, or fourteen rights. Documentation is important in all aspects of nursing care, not just medication, and as a previous poster said, the more the nurse is expected to do/remember, the less likely she is to do it. I don't think any of the posters who have pointed out that most med errors don't harm the patient are trying to say it isn't a big deal, just point out that it shouldn't be a fireable offense (most of the time). If an error hasn't harmed the patient, it's only by chance/luck. My own error was comparatively tiny (giving a dose that was slightly less than what was prescribed, and which the patient had been receiving for several days), but that doesn't matter in one sense--since I didn't recheck the dose, it COULD have been a major discrepancy, I wouldn't have known. I'd say that I'm very conscientious, and probably most of the nurses here are. Being a nurse is difficult. If I understand your post correctly, you're still a student or have just finished school. I know this is a cliche, but it just doesn't compare. Seven patients to pass meds on, with the phone ringing all the time, everyone demanding your attention, new orders coming in all the time, and that's just an ordinary day with no emergency--medication errors are an expected part of being a nurse. In fact, if a unit reports no medication errors in a month, they generally don't get praise; they get criticized for not reporting medication errors. Luckily for all of us, there are more and more changes to prevent medication errors. But it does always come down to the nurse who hands over the pill, in the end.