Skating on thin ice?(at my job)

carolmaccas66, BSN, RN · Aug 9, 2010

Oh OK thanks for that.

We in Australia (in the states I have worked in) usually just call it a med chart.

It is SO easy to miss med's though, especially when you have all these people to supervise and constant interruptions, and people's families constantly complain etc, and you are trying to concentrate. One patient I had complained loudly that he hadn't had his 4 pm meds; I explained because I was still doing them and I would rather be slow than make a mistake. I actually missed his med's because I didnt know the patients, and was running round trying to get soemone to point him out to me, then I probably got interrupted. Happens all the time. When you are doing meds for many patients, it is not seen as something that takes concentration and patience. Now, if someone interrupts me with a trivial complaint I don't deal with it halfway through doing meds cos I nearly make mistakes. I try to explain to patients & families how important doing meds is but they dont' listen, and I say it's my license on the line, to highlight the seriousness of doing this (I don't think patients care as long as they get their drugs to be honest).

The RNs that come on later usually do a check before the other RN goes off shift to see if all meds have been given. We have all done it I think; you are not the only one. The only other piece of advice I can give is get into a routine with meds, ie: sign straight after giving them, don't let others interrupt you with trivial things - tell them straight you are busy and will deal with anything later. And check your med chart again in a quiet place after giving them all to see if you missed any - this is what I am trying to figure out, but I find a routine helps.

nursep2b · Aug 9, 2010

I have concerns that you state your halfway through your NP program and you're making med errors!!!!!

Please elaborate.

Also, share how you've not made any medication errors and how you are certain you have not made any.

nursep2b · Aug 9, 2010

Oh OK thanks for that.
We in Australia (in the states I have worked in) usually just call it a med chart.
It is SO easy to miss med's though, especially when you have all these people to supervise and constant interruptions, and people's families constantly complain etc, and you are trying to concentrate. One patient I had complained loudly that he hadn't had his 4 pm meds; I explained because I was still doing them and I would rather be slow than make a mistake. I actually missed his med's because I didnt know the patients, and was running round trying to get soemone to point him out to me, then I probably got interrupted. Happens all the time. When you are doing meds for many patients, it is not seen as something that takes concentration and patience.

It's especially frustrating when you're trying to pass morning meds and therapy whisks your patient away, sometimes for the whole morning. We nurses do not have time to chase patients down when they are not on the hall. It's also hard for everyone not to show their frustration as the hallways are constantly packed with not just employees but patients and wheelchairs, you literally cannot walk through the mess, we're all on top of one another. The carts are a mess, too. So much time is wasted looking for things. The meds are in drawers, and scattered around the cart. This is a place with two kinds of staff; those who stay a short time and those who have been able to stick it out awhile. I really think this is the kind of job where there should basically be the same nurse assigned to one or two halls. A lot of the patients are high acuity (dialysis, brittle diabetics, etc) and there is just so much to know about these people and their needs.

There are also a lot of errors due to miscommunication. Doctor's appointments are frequently missed because someone failed to arrange transportation or sometimes the ambulance will show up and there will be nothing on the appointment book about any appointment (I suggested a case manager to the boss people after I noticed this. Guess it isn't in the budget).

Sometime's, I have wondered if Mcdonald's owns the facility because they are running the place like a fast food joint. I've gotten attached to the patients and feel like I could like it there, but it's hard to swallow the finger-pointing and criticism after you've spent most of the 12 hour shift running your legs off, sweating and really trying to see your patients have been taken care of. The bosses will acknowledge floor work is exhausting and can be very difficult but in the same breath berate you and make you feel like...you're skating on thin ice.

GRUNGE · Aug 9, 2010

i would not do that. that would be considered falsifying a legal document. thats grounds for having a licence taken away. then you will really be up the creek

carolmaccas66, BSN, RN · Aug 9, 2010

Hey nursep2b

Don't listen to others who act holier than thou...we have all made errors/omissions at some stage, or have nearly made them due to interruptions, being too busy, etc. No-one is perfect. That is why I'd rather take an hour and a half to do 30 patients' meds than do it in half the time, and make a huge mistake that I can't take back. I don't listen to people who say we must do our med passes quickly; I totally ignore that. Go slowly, or start your meds earlier and then you have a bit more time to do them, check right patient, sign off etc. When people criticise me, I always retort that it is MY license on the line and are they going to defend me in court if I make a mistake? Of course not; they usually shut up and leave me alone after I say that! As I also said giving meds is not taken seriously, least of all by patients and their families who don't understand the consequences; that is why I explain it to them.

If a patient is absent now I put 'A' in their chart if someone has taken them for an appointment for example. If they do come back fairly soon and I can still give their medication, of they may want pain relief, I still give it with the time, and we can either cross out the A write 'error' and say we have given the drug by still signing the chart (I was told this was still legal), or sign another square under the same drug (I haven't used an electronic drug system so don't know about that). The chart must still be legible as all nursing notes must be too. As long as we write SOMETHING it is legal. Also if a patient refuses first time in our big teaching hospitals, nurses don't have time to change their mind, so will just write 'R' for refused.

People will always make med errors - but if you find you are being interrupted too much or there is a reason why you are making errors, complain to that manager that warned you - and get him/her to do something about it (I complained re the facility I worked in last week today and they were good about it, but I ain't going back, even though they asked me to). Unless all us nurses complain as one and demand action, no-one will listen or do anything.

jkaee · Aug 9, 2010

There are also a lot of errors due to miscommunication. Doctor's appointments are frequently missed because someone failed to arrange transportation or sometimes the ambulance will show up and there will be nothing on the appointment book about any appointment (I suggested a case manager to the boss people after I noticed this. Guess it isn't in the budget).
Sometime's, I have wondered if Mcdonald's owns the facility because they are running the place like a fast food joint. I've gotten attached to the patients and feel like I could like it there, but it's hard to swallow the finger-pointing and criticism after you've spent most of the 12 hour shift running your legs off, sweating and really trying to see your patients have been taken care of. The bosses will acknowledge floor work is exhausting and can be very difficult but in the same breath berate you and make you feel like...you're skating on thin ice.

I've worked LTC for pretty much the whole 15 years of my career. So, what I'm going to say, I'm saying kindly (you can't always tell that on a BB).

You are correct in stating that lack of communication is an issue there. However, asking the company to add on another salary in their budget just isn't going to happen, and the kind of errors that you are describing do not require another staff member. If anything, more inservicing and education is required to all the staff that's involved in that process to make sure they understand explicitly what their responsibilities are.

LTC facilities are facing HUGE budget cuts. For a couple of years now, my facility has been really monitoring when staff are coming in and leaving to make sure we're not paying any unnecessary overtime. So, it's actually a good thing that management is watching out for this. If they didn't, you can bet a lot of staff would be let go because their budget wasn't under control.

Any LTC facility sometimes feels as if you're on an assembly line rather than taking care of people. Unfortunately, that's the nature of that type of work, at least until you get the hang of things and start moving faster. And, while we're on that topic, don't assume that management doesn't know how busy you are, or that they don't care. I've found that in most cases, they are aware. It's just their focus is necessarily on a bigger picture than yours is. And you won't understand that bigger picutre until you work in upper management.

It sound to me that you tend to be very sensitive, and take things as "finger pointing" and "criticism" when people are just doing their jobs. And it is managements job to make sure all the I's are dotted and T's are crossed. You'd be in a lot worse shape if they didn't.

As for the holes in the MAR, I suggest at the end of your shift you do a MAR check. We do that at the beginning of every shift at my facility to make sure there are no holes and that all meds were given. In fact, 3-11 checks 7-3's times and so on. If that's not something your facility wants to implement, then do it on yourself. That will cut down on holes and med errors.

Good luck to you, and stop being so hard on yourself. You seem like you want to do a good job, and that counts for a lot!

HollyHobby · Aug 9, 2010

You are not being singled out; as you've said, medication errors occur frequently and by different nurses. Management is doing the right thing by addressing the issue, but it doesn't sound like they're targeting you personally.

I do think they're being simplistic by telling you to "be more careful". This sounds more like an attempt to cover their own a**** rather than to solve the problem. It's very easy to put all the blame on the nurse; it takes a bit more work to figure out the process problem and take measures to fix that.

Because what you have here is a process problem, not a freaky coincidence where the system is perfect and mistakes are made only because a bunch of nurses are screwing up. I'm not saying that you, as a nurse, are not ultimately responsible when you make a mistake; what I'm saying is there is clearly a problem with the system that makes it too easy for you to make a mistake. If management is truly interested in reducing the rate of med errors, they will try to fix the process problem.

Others have pointed out some factors that are part of the problem: interruptions, distractions, perhaps a poorly designed MAR, etc. etc. The solution is to identify these factors and then eliminate (or more realistically minimize) them. I imagine all LTC facilities struggle with this issue, so learning how other institutions have dealt with this is a good idea. This is what your management should be doing, but even if they are not, you can research this on your own.

I work ICU, not LTC, but I once made a serious med error that was due in large part to a screwed-up MAR system. I was, of course, ultimately to blame for my mistake. However, I was able to identify the part of the system that made it easy for that mistake to be made. Other people had made very similar mistakes due to the same problem. The MAR was changed, so that particular mistake was unlikely to happen again.

Don't beat yourself up. If you do, you're just hurting yourself needlessly. Better to spend that effort on figuring out solutions. Then everyone at your facility will benefit and your patients will be safer.

carolmaccas66, BSN, RN · Aug 9, 2010

You are correct in stating that lack of communication is an issue there. However, asking the company to add on another salary in their budget just isn't going to happen, and the kind of errors that you are describing do not require another staff member. If anything, more inservicing and education is required to all the staff that's involved in that process to make sure they understand explicitly what their responsibilities are.
LTC facilities are facing HUGE budget cuts. For a couple of years now, my facility has been really monitoring when staff are coming in and leaving to make sure we're not paying any unnecessary overtime. So, it's actually a good thing that management is watching out for this. If they didn't, you can bet a lot of staff would be let go because their budget wasn't under control. Any LTC facility sometimes feels as if you're on an assembly line rather than taking care of people. Unfortunately, that's the nature of that type of work, at least until you get the hang of things and start moving faster. And, while we're on that topic, don't assume that management doesn't know how busy you are, or that they don't care. I've found that in most cases, they are aware. It's just their focus is necessarily on a bigger picture than yours is. And you won't understand that bigger picutre until you work in upper management. It sound to me that you tend to be very sensitive, and take things as "finger pointing" and "criticism" when people are just doing their jobs. And it is managements job to make sure all the I's are dotted and T's are crossed. You'd be in a lot worse shape if they didn't.

I have tried hard to be objective on allnurses but this time I am going to be critical of a posting.

For a start in my experience, every area of nursing is facing budget cuts. We all seem to be under exacting, enormous pressure as nurses. We are continually responsible ON THE FLOOR for more and more; not just caring for patients, but for all the medications & querying these, dealing with pharmacy etc; dealing with all the patient's family members' complaints; management complaints; all the Dr's complaints; staff shortages when people are off sick and management won't call in agency staff - the list goes on; I don't need to go into it all here again, just read most of the recent posts.

This is what really, really annoys me from a bedside nursing view point. People always say management is responsible for this and that, and has to 'look at the bigger picture'. But that is the very point of the frustration of nurses on the floor. It's akin to to building a beautiful, big house but not paying any attention to the foundation - if the foundation is no good, your beautiful house will eventually crumble. It's the same with management. They always say they are so much more responsible for everything; budgets, staffing, occ health & safety, whatever. They don't actually pay any attention to what is going on at the floor level. If they got out on the floor to see what problems were occuring over and over again, then maybe they could actually work with the nurses and define strategies to address and reduce, or solve these problems. And I strongly disagree that management 'know what is going on'. They may know partly what is going on, but always come up with the same excuses as to why such-and-such cannot be changed or even addressed.

For example, 2 of my family own and run a 2 million dollar net worth business. One brother actually runs the business and his office is actually next to the workshop so he can see what is going on, and he is out on the floor every day to define problems and solve them that day (if possible). In other words he nips it in the bud. The workers are happy, because he is always available to them to deal with any concerns. He is hard but fair which they appreciate. Everyone works hard and they are now making a profit after a few years. This is considered good management because it is management that WORKS ON THE FLOOR, not in an office in front of a computer in the back of the building where no-one can access them, or like some NMs who hide away and don't want to be disturbed - and the nurses are too scared to disturb them and air their problems. Then when we do, we are told the budget can't support it anyway and nothing gets done, ever.

I have done management jobs too, not at executive level (though I have worked closely with top executives), but I have helped run businesses and yes, you do have to take into account everything. But I used to be on the floor with other workers/patients/ and had an open door policy between certain hours, and yes I used to stay back a lot as well - that is part of the job. Most things come down to budgets that is true, but health care should not go by a certain budget - I have always disagreed with that. People will always get sick, their children and families suffer, health care should not be budgeted for or scrimped on. Maybe we need a more forward looking government to solve this problem, or better fund raising, I don't know.

Another thing that annoys me greatly is the fact that managers say 'we have been on the floor and done the hard work'. Well so what? What has that got to do with anything? In this I actually hear: 'I have done my hard graft and I'm not really interested in your problems, because I've dealt with all these in the past - please don't bother me'. The work environment changes over time, and the only way to know what is going on is to keep your nose to the grindstone. But it all seems to be too hard for management to deal with.

Tell me, what do managers actually DO? - and this is not a sarcastic question - I really want to know! They are supposed to be our sounding boards aren't they? They are supposed to be running the hospital/unit (whatever they are directly responsible for) and dealing with problems aren't they? But most nurses from what I have heard/read are too scared or intimidated by idiot managers who do not care and who do not know what they are doing, or who fob people off, and just don't do their job. I have had it happen to me again and again, and wonder in the dark hours of night HOW these people get and keep their jobs. Are they actually needed?

So from what you say, managers still kowtow to the CEOs/big bosses and couldn't care less about their staff or the patients - but the latter is the whole reason we are emplyed in health care and one that managers/CEOs forget - we ARE there to CARE FOR PEOPLE and we are suffering from the incredible stress of it all.

I have always said the hardest job in health care is actually looking after a person's needs - and their families. It's menally and physically exhausting, and there are so many brave souls that do it for years on end, then get discarded like old toilet brushes.

I think we could do without some of the managers if you ask me, or make it part of their job to take on a LARGE patient load a few days per week to see what is happening first hand, or even shadow staff who have the large patient loads. Do you ever see managers get 'let go' because there is too much overtime, or because a patient's family complained their 92 year old mum didn't get good care from their nurse, because the nurse was too frazzled and had no support that shift?

Respectfully, I find the above post incredibly insulting to floor nurses, and condescending, and typical of management thinking. It is like floor nurses are all idiots and have no idea of the so called 'bigger picture'.

Managers do not have to be like this - they CHOOSE to be like this, for whatever excuse/s they want to put forward, and yes it makes me furious that 'upper executives' or whatever title they want to give themselves, are like this. I have worked with some brilliant nursing managers who really tried to make a difference and cared not only about the patients but took a personal interest in each and every one of their staff, and believe me, they were so appreciated and sadly missed when they retired.

All I can say in closing is I am so, so glad I am leaving bedside nursing.

Esme12, ASN, BSN, RN · Aug 9, 2010

I'll try to get to the point but this is a little complicated for me. I'm a BSN and am actually halfway through a nurse practitioner program. It became necessary to find a job a few months ago and I began working at a very large nursing home. I've worked in a nursing home before, but it was small and a lot less busy compared to this one. The place is so crowded with laundry pushing carts up and down the hall, janitors buffing the floor, housekeeping pushing their carts and you pushing yours. It's literally like trying to maneuver through an obstacle course. Anyway, being a newbie I don't have the luxury of choosing where I want to work, so I'm usually floated wherever a nurse is needed. This is where medication errors are coming in. I don't have a problem on this particular hall where I usually work, but I got a phone call from the boss and was scolded because they had found holes in the MAR I had not signed and when the carts were audited they had found some medications I had not given.
She also told me she knew I had been moved around a lot but I was going to HAVE to be very careful. She also told me there are a lot of others guilty of the same thing (which you can look through the MARS at any time and see holes everywhere) so I was not just being singled out. Still, I can't shake the feeling I'm skating on thin ice, and it really stinks because I'm trying hard. It's bad coming home, sore and exhausted after running 12 hours and in the end you still get flogged for not being good enough. I'm on the schedule tomorrow and feel like I need to go talk to the supervisor, but I don't know what to say. I want to let her know I'm willing to do what I need to so I can be what they want me to be. I did tell her I was sorry I turned out to be a disappointment and she told me I wasn't a disappointment but it sure sounds like I am. Jobs aren't easy to come by around here so I'll be up a creek if I lose this one.
Any advice?

Who cares what everyone else does! care about what you do!!!!!!!!!! You are responsible for you legally....in a court of law "everyone else does too!!!!" will not save you! You are the NURSE and it is your responsibility to give meds. Would you find it acceptable if the nurse wasn't giving your mother,brother,father or child the meds they needed because someone is waxing the floor. She is right you need to be careful, you don't give lasix someone goes inot heart failure.......Nurse Practioner? I applaud your ambition but you need to knuckle down and realize that alot of responsibility is in your hands........How will you deal in a busy MD's office or ED urgent care and just not orde renough antibiotcs for a wound infection or you missed the STREP POSITIVE because housekeeping came and dumped the trash! Check Check and reCheck! Meds must be given. JACHO...... right med, right patient, right time, you know the drill! :up: It isn't easy but anything worth having is never easy...... :twocents:

jkaee · Aug 9, 2010

All I can say in closing is I am so, so glad I am leaving bedside nursing.

Wow...what a reply!!

I didn't mean any offense, and BTW, I am NOT a manager, nor do I have to deal with budgets or anything of the sort. I have recently left lower level management (where I had to run a 60 bed unit AND work the floor every day), and the fact remains that we are facing budget cuts. I am NOT advocating working short handed, or in dangerous situations....I simply stated that instead of asking for another staff member, educate the ones that are there to do their jobs correctly.

You are preaching to the choir, darlin'....I have always stated the the floor nurses need more help. It is so easy to get burned out, but what I find terribly offensive is that you assumed that I was a manager, in with the "big guns" and rooting for their side. And that couldn't be farther from the truth. You have no idea what I do now or have done in the past. And I also know very well what is a good management style and what is not.

To be honest, I didn't read all of your post, because while I was quoted in your reply, it didn't have any relation to the point I was trying to make, and I honestly don't know where all that came from. I'm not pro management, but I'm also not out to bash everyone that's in management. They have jobs to do just like everyone else that works in healthcare.

And that's all I'm going to say on this topic.

coolpeach · Aug 9, 2010

I am an new RN in a hospital with 0 LTC experience so I will do my best here. Remember Pt. Safety 1st. I can't imagine NOT giving a med Period. You MUST give the pts their meds end of story. Imagine if one of them being ill or died because of a missed med that you didn't give. Do what you have to do in order to give each pt. safe care. Everything else comes next. If you still feel overwhelmed asked if you can cut your patient load down for a couple of weeks until you get your time managment routine in place. You could also ask if someone could work with you personally for a week or two to help you sort it all out. It seems to me that they would see you asking for help as a + that you are trying your best to correct the situation.

nursep2b · Aug 10, 2010

Yes, I was a little insulted at the assumption I can't see the bigger picture. As a matter of fact, I have worked as a part of administration in a small LTC facility but left because I felt guilty taking a paycheck.

Double and triple checking yourself is great but there are only so many hours in the day. I had someone in the floor today and that set me back a good hour. The bottom line is that in a LTC setting continuity of care through having the same nurses on the same floor is imperative to reducing and eliminating errors as much as possible. To the newbie who could never imagine not giving a med...I think you may be in for a rude awakening. No one is immune to med errors, I don't care who you are.

I also think you will be hard pressed to find a NP or even a doctor who does not make mistakes, I don't get the shock and head shaking over a nurse practitioner student making mistakes. Being a np doesn't mean you are flawless by any means. We find md and np mistakes more than once in awhile.