guest940422

I started working in UM a year ago. They want strong clinical background, charge experience, and really look at extras like being certified having a BSN and committee work. I also never stopped applying for jobs... for real... like submitting applications several times a week for over a year. I started working for disaster health services at the red cross as a case manager. The training is annoying, but once that's over you do virtual case work on your phone with a computer. They don't have minimum hour requirements so you can just do it whenever you have a little time (like never more than 20 min here and there). It was the only way i could find to get experience without already having experience. my boss said that was the only reason they were willing to interview me.

It doesn't matter if you have the pieces together. It doesn't matter if you can prove it. All that matters is the red flag. As mandatory reporters we are expected to report to social services (not to our supervisor, or the facility social worker, or to the doctor) any suspected abuse. We aren't trained criminal investigators, no one expects us to have solid evidence. We are trained professional healthcare providers. We are often the only people given access to these kids. And we can see discrepancies no one else would think to look for. I'd rather put 1000 families through the stress of a CPS investigation than let one kid get abused right under my nose. I've seen parents hide diapers to make it look like their kid was in renal failure, i've seen a 3 year old with a positive tox screen for cocaine with a doting inconsolable mother at his bedside worried about his most recent cardiac arrest, a mom that was pouring just enough saline in her daughter's gtube to screw up her electrolytes and get her admitted every month, and another who was caught on camera contaminating a PICC line with feces. This is so much more common that people think it is. We run to the phones to alert authorities if injuries are not consistent with the report the parents give us. Our culture needs to evolve to have the same urgency when the presenting clinical picture is also inconsistent. If you still aren't sure, then think about the fact that you are setting yourself up for some serious liability. failing to follow through with a report, especially if you have documented suspicions, can loos you your licence and expose you to civil litigation. It's no different than documenting someone is suicidal but not doing anything about it. When they kill themselves, it's on you.

Ya you're right, they did say someone had made a report at one point. Even that doesn't mean much, CPS is far too understaffed and overworked. I think i just got rawled up because he was on camera stating he suspected abuse but couldn't report it without proof. Its more common than people think... typically its parents/caregivers refusing to believe their child is well or convinced they are sicker than they are. It is exceptionally rare that they are actively making the child sick. I just keep thinking of all the reports I've had to make over the years and all the professionals she was paraded past and no one helped her... that's a damn shame.

OK… let he who is without sin cast the first stone. I know I haven’t always been a perfect healthcare provider, I know I have screwed up and possibly put lives at risk, I’m not pretending I’m perfect… but I really need to vent here before I say something somewhere where I’ll get more than a tongue lashing from my peers. I watched “Mommy Dead and Dearest” a few weeks ago and I just can’t get it out of my head… I’m just angry! Dr. Bernardo Flasterstein, is a neurologist at Children’s Mercy Hospital. He is being interviewed in this documentary saying “I had a big doubt about the whole thing from the beginning”!!!! He wrote in his documentation that he believed the mother had Munchausen syndrome by proxy and publicly admits he never reported it because too many people believed she was really sick so “All I could really do was put it in the chart” (cough cough) B&!! $&*T (cough) I’ve been a mandatory reporter since I got a weekend job in a daycare in high school…. WHEN I WAS STILL A MINOR I had to take training on identifying and reporting suspected abuse. The key word here is suspected… you do not have to confirm abuse to be responsible for reporting it… confirming it is CPS’s job. If you suspect it, you are responsible for reporting…. And not just any reporting, telling social work or your boss and assuming it got to CPS isn’t good enough… you are responsible for making sure the report goes to the authorities. The first time I received this training, I was 16 years old, Gypsy was 11! I understood, why didn’t her doctor??????? In 2007 he wrote a whole provider’s note about not thinking she was sick... they hold it up in the movie… pause it you can read every word…. Years later she is on trial for murdering her mother. As healthcare workers we are held accountable for everything, from paying child support, to defaulting on our student loans, to getting a DUI… any of those things can leave us liable and put our careers at risk. How is this man able to work after openly admitting he knew and did nothing?!?!?! Screw it, let’s put him on TV so he can tell us what we already know and feel sorry for him because no one would have listened any way if he had bothered to speak up! I mean come on can we at least use this extreme case to learn and prevent other severely abused kids from slipping through the cracks??? He said we call social services in the case of neglect but that wasn’t what was going on in this case… long before Gypsy got her boyfriend to murder her mother, Dell Children’s hospital had cameras installed to catch a mom who was contaminating her child’s PICC line. This is hardly a new form of abuse and this man knew what he should have done and just chose not too. OK thanks I just needed to vent…

It'll happen, just not on your schedule. Start acting like a charge nurse now so its easy to see you in the role. Education is great but it won't make you a better nurse or leader, people want to follow someone who is willing to work in the gutter with them, management wants to promote people who wont rock the boat and aren't too idealistic (it helps to understand the financial side of things too, saving money and preserving resources will get you noticed far more than picking up too much OT) Don't over-extend yourself by jumping into every project/committee you can. Instead pick a favorite and work your way into a leadership role in that committee... when people see you spread too thin because you want to have your hand in everything you just seem too eager... it is good to have a focus and priority then they can see you leading in that aspect, you will feel like less of a threat to your coworkers too.

While leading the charge and advocating for evidence based practice sounds like a fabulouse romantic though, its a great way to piss off your coworkers and put a bulls eye on your back. You will get pushed out of there so fast youll wish you had just quit. 1. Lead by example, if they want to ignore patient safety when they are working you cant change them, but you can refuse to do it when you are working. Insist on proper time outs and consents when its your patient, you'll still make enemies but not as quickly 2. Use trigger words, " case delayed due contamination of sterile field" "for patient safety requested MD consent pt prior to procedure" "hostile Negligent..." Some things (if they are in writing) are too big of a liability to ignore for mngt 3. Change can't happen overnight, incremental nudges work better than massive shifts in culture. Try to get a unit quality council started or find another way to empower your team members to be part of the process. 4. Find another job, this isn't a step by step process just a list of ideas. If the culture doesn't look like it can be influenced and the practice is against your ethics than do you really want to work there anyway? Decide if you willing to fight this battle... because its going to be a long time before things are the way they should be. 5. evaluate what is most appropriate for this facility. Not everything can reasonably be changed, concider resources and pt population... Good luck hope that helps

So everyone is sort of echoing my thought process I know a consent isn't valid even if it's signed in all the right spots if the patient never spoke to a doctor, but I'm in a screwy position because I'm taking the patient to the procedure knowing they aren't properly consented. to add to the cluster I'm sedating 90% of these patients so even if they didn't get properly informed on their procedure I'm giving them proper informed consent on sedation (amazing how many people mistake me for an Anesthesiologist) So I can't just refuse to sign because I need them to sign for the sedation before I give it under my license. Ethically I know I'm telling them everything the MD would be telling them, but I'm answering questions I'm not licensed to answer and I don't think I should be put in that spot. Before I take a stance on this, I would really like to have my facts straight. This is a "don't rock the boat" sort of organization and it is very likely I'm going to need a back up job before this is over.

I'm working in a non-teaching hospitals radiology department. Every procedure we do requires consent. In my past life of working in the ICU either the resident had to call the family for consent ahead of time or get the order for it to be deemed emergent. I was always told to never even witness a consent form unless I literally saw both parties sign the form. Even when our doctors do bother to see the patient first, they just run through the procedure in two sentences, tell them to ask the nurse if they have any questions, sign a blank consent form, then leave the form on the table for me to fill out and have patient sign. The first time I had a family member that wasn't present my coworker called them for me, consented them over the phone then handed me the phone and had me verify consent... they never spoke to a doctor.... two RNs don't make an MD... or did I miss something? Then I started seeing this with ICU patients too, instead of bringing the families down, the ICU nurse would just consent them upstairs and have the Rad sign the form when they got downstairs. I've even seen orders that state "consent patient for procedure" How is this a legal informed consent if the patient or family never spoke to a doctor? Should I be witnessing the form being as though I didn't see the doctor consent the patient? Will i be liable for any of this? Or is it ultimately the Rad's responsibility to get permission to do the procedure? I'm in Texas, I tried to go through the practice act but it's really vague and I don't have an attorney to interpret it for me. Hoping someone here has thoughts.

I'm guessing you mean you are still in your "probational period" and don't think the job is a good fit. Yep they have to pay you for the work you did even if it is orientation. This is why a lot of jobs don't let you accrue PTO until after that period is over, if you leave they don't want to have to pay you for your PTO also. If it is a big hospital system I would take the time to hit up HR and see if you can transfer to another unit rather than quite all together though.

I work in radiology and sedate patients every day, our hospital has a scanning system but we don't scan any of our meds, the patient is either covered or inside the scanner, the meds aren't ordered ahead of time so they aren't on the patient's profile, except in this case because the doctor is scrubbed in and gives verbals during the case, the time-out is the patient check, since we do anesthesia cases also our Pyxis has paralytics in it and all our meds have to be an override, if you are not trained or in too big of a hurry, i can see how you could grab the wrong vial, i've written several safety reports because the wrong meds were in drawers or because the way the pyxis was loaded made it too easy to grab the wrong thing (you have to pull it out the whole way to get zofran if you only pull it out halfway you get amlodipine) I agree the nurse was negligent, but blaming her won't save anyone's life. Learning from this can. -Don't give meds you aren't familiar with, if you aren't sure look them up. In a genuine emergency someone else will be there to ask -If you aren't trained in an area or aren't comfortable in a task refuse the task no matter how pressured you may feel -No ICU patient should be out of the ICU without an ICU nurse or an anesthesiologist assuming care. If the nurse covering for lunch wasn't an ICU nurse or sedation nurse either lunch break has to wait, the scan has to wait, or someone else needs to take them -No ICU patient should be on any table or in any scanner without monitoring and a nurse monitoring them -If a patient is sedated for a scan or procedure (even if all you gave them was 0.5 of Versed) they have to be monitored for the duration of the scan ICU or not -Know what resources your hospital can pull out of a hat, I've call my house supervisor after hours because the patient's ICU nurse had to leave since his other patient was coding upstairs leaving me alone with a patient that had unstable pressures, needed drips titrated and I had already started sedating. She sent me a rapid response nurse to manage the drips so I could focus on the sedation

Ahhh my favorite yearly argument Amen! Thank you! No one is forced to do anything, we had the options of getting vaccinated or going to nursing school, get vaccinated or wear a mask, get vaccinated or don't work in the hospital... you always have a choice my dear Why yes, hospitals love the double standard, "Stay home if you are sick we care about our patients' health" then only give you 4 absences a year before you get a write up when you work in an infectious disease floor Really? But immunizations are not just for at risk populations, they are for the people around at risk populations. Healthy people like us get vaccinated to protect the people who can't (cancer patients, autoimmune diseases, transplant patients, legitimate allergies, seizure disorders, infants not old enough yet) even if you don't work directly with these patients, you will indirectly contact them being in the hospital. Herd immunity doesn't work if only sick people get vaccinated. The flu vaccine is never perfect, but youtube a video of an infant in the PICU with the flu and you won't wonder if you should get it anymore... promise.

Everyone is different, see a psychiatrist, don't try to be your own doctor (we are all guilty of this). They put me on Zoloft first but it gave me stomach issues, Prozac was doing a good job for many years until I had a near-death experience in a flood and they decided to change me to Wellbutrin to battle the PTSD along with the panic attacks. It's not a PRN though, you have to take it every day and then you may have a prescription for a benzo if your anxiety is severe or you know you will be in a situation with triggers. Think about it like Asthma, you may take Singulair daily to avoid symptoms but occasionally you need a rescue inhaler for wheezing. You take the SSRI or other depression med to prevent anxiety symptoms not treat them after the fact. But you can't be managed by a PCP you need to see a Psychiatrist and you'll have to go every 3 weeks for a little while until you figure out what works for you. Problem with Propranolol is it treats the symptoms of anxiety and panic attacks but not the cause, a lot of doctors have started doing that because they don't want to prescribe Benzo's anymore, same with Neurotin.

I've had panic attacks since high school, they've become more managed now and have almost disappeared. I worked in ICU most of my career, the weird thing was I never had anxiety or a panic attack once in 10+ years working PICU (beyond typical what did I get myself into new grad anxiety). I think it was because I was always so focused on my patients and not on myself... but that is just speculating. See a psychiatrist, they can decrease or even completely prevent attacks with SSRIs or other depression meds, and drugs like propranolol and neurontin are also used off label for different kinds of attacks. I have to take a Benzo if my anxiety gets too severe, but that is rare. If you had Diabetes would you let that stop you from advancing your career?

I've worked places that do this and then run a "flush bag" behind the antibiotic for 20 mls. Drives me nuts because I have to make a special trip to hang the flush bag and the pump beeps twice at the end of the infusion (night shift sleeping babies/parents). I tried teaching people how to use a primary NS bag, to flush, pointed out the same bag can be used for multiple antibiotics, showed people how it decreased the number of steps they took to hang a med.... culture wins. Do your job the best way you know how and don't worry about everyone else. They are practicing under their license and you are practicing under yours. As long as you know you've done right by your patients you're in good shape. Openly teach anyone who asks about the way you hang your drugs, practice catches on better when people see it than when told to do it.

I'm really interested to hear about how other people view/perceive/promote high value care. I'm fairly new to my unit, everyone prides themselves on being "cost aware". People hold each other accountable for the tiniest of extra costs. I've been counseled by more than one colleague since I arrived for things like forgetting to credit a patient back an IV catheter or unused oxygen tubing. But this is where the culture falls short. We do MRIs with anesthesia for patients who have never been in an MRI machine before in their lives. We don't even attempt po sedation or moderate sedation if they request anesthesia. This week I sedated an 86 year old man for a biopsy who was a DNR, had refused chemo, and was being discharged to hospice care. There went at least $5K plus unnecessary risk and pain, along with an extra day in the hospital and no one could tell me why we were doing it. We order pre-procedure tests and no one can explain why coags from last week aren't good enough before an angiogram when the patient isn't at risk for a bleed. All I get is "you have to have a PT/INR within 24 hours of an angio..." but no why. Hourly portable Chest Xrays on post-lung biopsies... why hourly? Why not just once in x hours and prn if symptomatic? "Because that's how we always do it" We order CMPs for patients who really just need a creatinine and GFR before a contrast study, send blood gases to lab when we have point of care tests that are faster and cheaper, order UAs on patients who only need an HCG, and the list really just keeps going. I was always taught "because it's ordered" is never the answer to "why?". Now, when we are over-spending trillions of dollars a year in US healthcare, that is the answer everyone gives me. So we all go out of our way to save the patient/hospital $10 for an IV catheter, but not $10k for an unnecessary procedure. Any thoughts or advice on even incremental steps towards raising mindfulness or educating?

I tell patients 0 is sitting pretty on cloud nine, and 10 means I can punch you in the (insert location of pain) and it wont hurt any more than it does right now. This is adopted from a knee jerk unprofessional reaction to a 16 year old who told me she had a score of 10/10 while checking her facebook (I was a new grad and you can get away with saying what you are thinking with teenagers). I tend to get pretty appropriate answers from people with this strategy. If all else fails, use an objective pain scale. Since we went and got half the population addicted to opioids, pain is no longer defined as "whatever the patient says it is" Pt reports pain score 10/10, FLACC score of 3, hr and bp at baseline, currently involved in non-health related conversation with visitor while playing video games, non-pharmacological interventions applied: distraction, decrease noxious stimuli, encouraged visitor interaction, positioning.... .... will reassess in ___ hours/min

I was a cutter when I was a child (12 years old), it was a dark and difficult time for me and that is really all I care to share on the topic. Now where I once had scars covering my arm, I now have a full sleeve of what even the biggest critics admit are beautiful tattoos. I live in Texas, long sleeves are not an option 10 months out of the year. I no longer have to come up with ridiculous lies about every time a stranger looks at my arm less I be judged for my pre-adolescent lack of coping skills. I already loved tattoos before I decided to cover my scars, it was my way of coping and turning pain into beauty. While i admit some heavily tattooed individuals are sadists and enjoy pain, most enjoy art, or use tattoos as a form of expressing themselves. It is the best social filter I've ever encountered. You learn a lot about someone by how they do (or don't) respond. I can attest after decades of therapy and self exploration my tattooing is not a form of cutting, and if anyone fits the stereotype it's me. I'm not saying this is true for everyone, but this is a very dangerous generalization to adopt. End Soapbox: Per my career I have been blessed to always work places where no one cared about my tattoos. Working in pediatrics I was permitted to wear short sleeves. But you should always be realistic and know people have bias. I've never shown up to a job interview with visible tattoos. I even wear makeup on my hand to cover the edge of my sleeve. I've had one boss admit they would not have hired me if they had seen it in the interview and they were glad I had it covered. She makes me wear long sleeves to work, and the dress code backs her up so I do it. Of all the things you can fight with your boss about, dress code is just not a battle worth fighting. I recommend wonderwink undershirts. They are super thin,comfortable, durable, soft, and breath well. You can role the sleeves up when you are hot and you just don't care. I work in procedures for hours at a time with a lead apron and sterile gown over my long sleeves and they don't make me any hotter than I would have been.

I know the demands on nursing students is different now than it was when I was in school (and that wasn't very long ago). When i was a student, you picked your patient the night or day before and did all the research and paperwork before you got to clinicals. Now I see more and more students showing up the day of with stacks of paperwork they need to fill out on a patient they pick in the morning and be ready to present this by post-conference. So if your teacher is making you spend your clinicals on the computer then I don't know what to tell you. That situation aside, I feel like clinical experience is sacred and you only have a finite amount of it... don't waste it working on your homework doing care plans or studying for exams. We are really busy, we don't stop to hunt you down when there is a great learning opportunity. Stay on your nurses heels and you'll get more out of it. Do the grunt work. Vitals and bed baths may not be what you thought you were signing up for, but support staff is a luxury you may never have. You need to be able to do those things without thinking, they need to be in your muscle memory so you can be simultaneously assessing your patient and noticing trends prioritizing your day and other things that will come later. You don't want to graduate and still be having to think and focus on which way a blood pressure cuff goes. The only stupid question is the one you don't ask Never stand when you can sit and if you see a bathroom use it keep a mini sample size perfume bottle on you and spray it inside your mask for tasks that might make you sick from the smell (12 years in and I still can't handle the smell of puss) You don't get anything you dont ask for. If your patient is going to the OR for surgery ask if you can go to observe... you may never get another chance and even though your school doesn't get OR rotations they will almost always say yes (just don't touch anything) I work in IR, we don't take students, but if a patient has a student attached to them and the student asks I let them stay and observe. When I was in school I got in to a ton of specialty areas doing this. If there is a code, don't just watch in the doorway, walk in the room, find a spot out of the way You will see lots of nurses do things that are not the way you are being taught in school. Some are open minded and would love to learn the latest techniques from you. Most have egos and pride and do not want a student telling them how to do their job. the fastest way to get a nurse to ignore you and not want to teach you is to tell them they are doing something wrong or pull a "well we learned it this way because...." If you like a unit you are on, ask for a reference from a preceptor and get the manager's card (its usually at the desk) start thinking about job hunting now and make those contacts. This is going on your resume after all.

You're welcome to read the article I posted about my experience swimming out of my car after getting hit by a flash flood during the 2016 tax day floods in Houston. That wasn't even a Hurricane. If it had taken me seconds longer to snap that I needed to role down my window, I would have been one of the people who died that day too.

You're right, It wouldn't have been. I bring people patients up or go get them a lot (even when I really don't have time). I know I have the luxury of only being responsible for one patient at any given moment. I have 4 more stacked up in pre-procedures which is why I call ICU before the patient comes off the table in hopes of timing their arrival to keep from slowing down the flow. A lot of the ICU patients are on pressers and the IR nurses give sedation and circulate. Not all of us have ICU background. The ICU nurse is expected to stay with the patient during the procedure. I don't make them stay unless the patient is really unstable. I think that added to my irritation. But I can't expect someone to read my mind. Instead of getting huffy, I should have asked her to come down and monitor the patient while she waited for escort, then gone to get report on my next case. I've never worked in management, but in my experience anyone who has been on FMLA has their position held. Ive had managers say they are applying to add additional positions to the budget during hiring freezes while people are out on fmla. So that makes me believe their specific spot is still theirs We've gotten transfers before and not known they were on IFMLA, when they apply for transfer the unit they are coming from can't disclose it. It could cause the unit they are applying to to discriminate based on a disability.... you know... sort of like I was doing Travel Nurse, I guess in that moment I was trying to make my measly almost-12-years of nursing experience sound impressive. Instead of just blowing off an ignorant comment, I went off on a childish narcissistic angry rant... not my finest hour. I'm sorry you went through that, I understand you not reading the comments. The long and short of what you missed is I was talking about the population of women who aren't having any of these symptoms but still want to do less. This was me venting at the end of a rough day and it was never my intention to piss off the better part of the nursing community. I did, however, learn a lot from the 70ish subsequent comments and my perspective has grown because of it. If anything, this experience has made me take a hard look at the way I treat/view/judge my peers. If you do decide to go back and read the comments, I beg you to please try not to judge me too harshly for some of the things I wrote... again not my finest hour.

Preach! I just ran screaming from my orientation shift in the ER when they wanted me to start floating PRN. Ever since I have tried to see the hospital as a whole and not blame one department for things backing up. We regularly had 16 hour wait times and were on diversion for weeks at a time. Everyone wanted to blame the ER for running badly, I realized there were things I could do to help from the ICU too. Decreasing ratios house-wide lowered wait times pretty significantly. I think some of the CNS are working on publishing that data.

It helps me to line up the units 800mg 500mg ----------------- Xml 1ml 800mg=500ml/X x500 x500 ------------------ 1.6ml =x then 3X for the three doses =4.8 ml or 2400mg whichever it asked for does this make sense? hard to type it out in the box

True, even hospitals in known disaster zones won't call in essential staff every time they should. It costs too much. They wait and see often far longer than they probably should and end up waiting until it's too late for the "ride out" team to get there. This leaves people stranded at work and others unable to safely get there. I have an article posted about when I had to swim out of my car in Houston when I got hit by a flash flood. no hurricane involved. They never called a carla. We got more rain in 24 hours that night than we did during the week of tropical storm Allison. Hindsight's 20/20 they weren't sure the storm would hit and didn't want to drag hundreds of staff members in just to send them home and make them mad. Each time something like this happens we learn (I did). Now I hope you will have time to weigh risks and benefits, talk about it with your family (when you aren't in crisis mode with an immediate looming threat), and know without hesitation what the plan is if this ever happens again.

Tenth grade world history class (Ironic I know). In first period they made us watch the news for the first 20 min every day. When I came into class everyone was laughing and joking about how some dumb drunk pilot accidently drove a plane into the side a skyscraper in New York (15 year olds what can I say). Our teacher was losing the fight to make us understand actual living people were inside the building we were laughing at. He couldn't get us to take it seriously. I was watching the footage live when the second plane hit the other tower. This is apparently what it takes to get 30-some-odd narcissistic teenage millennials to shut up all at once (no one was calling us that back then but you get the idea). The school cleared out in less than an hour. Students with a driver's license or a parent could leave without a note. I was 15 and my mom was at work in the CVICU. My teacher let me leave with the campus cop who lived down the street from me when he flatly said he was my dad.

I know it is time consuming, but I never have more than one patient's meds on my person at a time (except in the example with the big multi drawer carts which have been phased out in a lot of facilities). It is just too easy to make a med error. I start my shift by making sure everyone's meds are accounted for so i can request missing meds, then i gather room 1's meds take them to room 1 administer. Go back to the med room gather room 2's meds repeat... Now this is, in part, because i came from PediLand, so room 1's Diuril and room 2's Diuril will almost never be the same dose. But even in school I got in this habit to avoid double dosing a patient or mixing up meds. I'm sure having everyone's meds on me at the same time is faster, but I've never done it that way. If this isn't really a safety issue that applies to your unit the other thing to consider is joint commision. All sharps have to be in locked containers if in public spaces so only clinical staff have access. If there are needles in these drawers do they lock? Medications have to be stored in locked areas where only licensed staff have access, so the drawers have to lock, and only nurses doctors or RTs should be able to get to them. If you have more than one patient's medications on you; the other patient's meds are supposed to be locked to keep from being contaminated when you are in the room. This might be why they are making you change your practice since there is only one unlocked drawer on the new carts. Have you considered sorting meds for each patient in the med room ahead of time, and dividing them up maybe in lab bags with the patient's sticker? That might be a little more time consuming but not much more than what you were already doing. As per keeping meds safe. It isn't uncommon for nurses to tell families they can't get them something because they first need to safely administer medications. "I would be happy to, but first I need to give my patient their medications" People generally know that is more important. If a patient can't take a narcotic right now, depending on the hospital, I will either put it in a med cup with their sticker covering the top and secure it in the med room. Or waist it and pull another when they can. Again the lab bags have always been my friend. I put their meds in the bag, sticker the bag, and tape it to the cart. I even tape an extra one for small trash (blister packs, alcohol swab wrappers, unit dose wrappers) you can't walk away from the meds on the cart, they need to be in your hand. But at least they are all together.