Don't let dangerous drug errors happen for inpatients being held
Don't let dangerous drug errors happen for inpatients being held
Timing of medications in the ED is a 'big problem'
When patients are held in the ED for hours waiting for an inpatient bed, you need to give medications normally not used in the ED, at regular intervals, and be certain that floor nurses know what was given and when. Is this the "perfect storm" for errors?
In this scenario, you are acting more like a medical/surgical nurse than an emergency nurse, says Diane Fox, RN, BSN, CEN, clinical resource coordinator for the ED at St. Vincent's HealthCare in Jacksonville, FL. "Down in the ED, we are not used to giving five pills at one time, with timed blood draws and timed meds," she says. "We have a hard time changing our way of thinking."
Kathy Roberts, RN, an ED nurse at University of California — Irvine Medical Center, says that as an ED nurse, you "typically expect to care for patients that would be discharged or directly admitted without delay to an inpatient area."
Deborah M. Dixon, RN, MSN, APN, ED educator at Summa Health System in Akron, OH, says, "In the ED, we are not big on timed things. So, getting medications timed appropriately has been a big problem for us." Dixon includes information on inpatient medications, such as clopidogrel bisulfate, glucophage, and insulin, in the ED's monthly newsletter. [Two sample issues of the ED's newsletter are included.]
Here are three ways to avoid missed dosages with inpatient medications:
• Give the first dose in the ED.
The timing of inpatient medications is "always a challenge because we are not familiar with the schedule upstairs," says Fox.
ED nurses give the first dose of medications ordered for "anything that is going to affect the patient's condition," says Fox. "This may save two or three hours. We know there will be a delay between the patient leaving the ED and actually getting to the floor. So if they require antibiotics, they do not leave the ED until they are given."
When the ED physician makes the diagnosis of pneumonia, for example, antibiotics are ordered so they can be given immediately by the ED nurse, without waiting for the admitting physician to order them. Likewise, if an admitted patient has a low potassium level, they are given a loading dose of potassium.
When ED nurses receive the medication administration record (MAR), "we go back and see if they have received the medication that is listed," says Fox. "If the medication is given 'bid' and is ordered at 7 a.m., and we don't get our meds until 10 or 11, we make sure they get that first dose, so there is no delay."
• Use the same computerized MAR for ED and admitted patients.
Frank Rocco, RN, ED interim nurse manager at Thomas Jefferson University Hospital in Philadelphia, says, "This cuts down on confusion because it is consistent for every patient, no matter what department you are in."
Before the electronic MAR was implemented, ED nurses simply documented the medications on the patient's chart. Then the floor nurses would have to compare their own MAR with the ED nursing notes, which caused confusion. In addition, "the computerized MAR automatically creates future doses that the ED nurse can check on," he says.
At Summa Health, ED nurses previously handwrote the medication orders on the nursing notes, and often they weren't timed appropriately. The MAR's generated times, according to the schedule on the floor, might be 8 a.m., 2 p.m., and 6 p.m., for example. "But if we gave the last dose of antibiotics at midnight, we wouldn't give it at 8 a.m. like the floor MAR says. So, we would have to change all the times for that antibiotic to be on our schedule," Dixon explains. "So, we keep medications on our schedule as long as the patient is in our department."
Now, if the patient hasn't been admitted yet, and he or she won't be getting a bed for awhile, ED nurses use the physician's order entry to determine the medications that need to be given. "As soon as something new is ordered, a flag comes up onscreen. When you complete the order it goes away," says Dixon.
Once the ED patient is admitted, the pharmacy prints out the same medication cardex used by the floors. "This gives us an up-to-date list of what we still have to do," says Dixon. "This helps to close the link of communication between the ED and the inpatient units. Once you begin to transfer medications onto a different form, you run the risk of creating errors that are easy to prevent. This way, mistakes don't happen on the floor. We are very clear about what we did and what we didn't do."
• Store inpatient medications separately.
At Thomas Jefferson, admitted patients are assigned a bin in the ED's automated medication dispenser. "All of the routine medications are obtained by the pharmacy and stored in one secure place, instead of the ED nurse having to individually gather each medication," says Rocco.
Often, routine medications for inpatients are not part of the inventory in the ED's automated medication dispenser, says Michele Bascom, RN, an ED nurse at The Hospital of Central Connecticut in New Britain. "Previously, inpatient medications were paper-clipped to the chart in a small, sealable bag," she says. "We now store these in the secured medication room, inside a small movable rack of drawers with a patient label affixed."
At Summa Health, "we try to run one section of the ED like a mini floor," says Dixon. "We are only dealing with admitted patients, so they don't get lost in the shuffle."
The ED is broken up into four "zones," with Zone 1 all private rooms, where admitted patients are placed whenever possible. "Once it has been determined that the Zone 1 will be housing only admitted patients, nurses place the medications into the cart and label the individual drawers with the patients' information," says Dixon. "We have everything we need at our fingertips."
Sources
For more information on medications given to admitted patients in the ED, contact:
- Deborah M. Dixon, RN, MSN, APN, Emergency Department, Summa Health System, Akron, OH. Phone: (330) 375-3617. E-mail: [email protected].
- Diane Fox, RN, BSN, CEN, Emergency Department, St. Vincent's HealthCare, Jacksonville, FL. Phone: (904) 308-5020. Fax: (904) 308-5050. E-mail: [email protected].
- Kathy Roberts, RN, Emergency Department, University of California — Irvine Medical Center. E-mail: [email protected].
- Frank Rocco, RN, Emergency Department, Thomas Jefferson University Hospital, Philadelphia. Phone: (215) 955-2679. E-mail: [email protected].
Be sure floor nurses know what meds were given You risk duplicate or inappropriate orders If you're not clear about when medications were given in the ED for admitted patients, "cardiac meds or antibiotic orders may be duplicated or ordered at inappropriate times," says Kathy Roberts, RN, an ED nurse at University of California — Irvine (UCI) Medical Center. Sending medication information At St. Vincent's HealthCare in Jacksonville, FL, information about medications given in the ED is sent electronically via a pre-printed medication administration record (MAR) or a faxed report. "The floor nurses may get confused about where to look for things on our paperwork, as they are not familiar with out ED orders. So, we also mark it on the admission orders and put it in our notes," says Diane Fox, RN, BSN, CEN, clinical resource coordinator for the ED. If the printed MAR is not received from the pharmacy by the time the medication is ordered, a blank MAR is used for documentation. "That is sent with the patient to the floor," says Fox. [The MAR used by ED nurses at St. Vincent's HealthCare is included.] Direct communication between the nurse and physicians is always the best option, says Roberts. "However, this practice is often seen as an inconvenience for the physician. In some cases the admit physicians do not notify the bedside nurse of changes in orders," says Roberts. At UCI, ED nurses check the computer every two to four hours to check for those changes. "Thus, stat orders and medication orders that have been modified can be missed if the nurse is not diligent in making these checks," says Roberts. "All admit orders are entered in the computer so medications and dosages are easily read. Times for administration are identified so nurses should not miss routinely scheduled medications." At St. Vincent's, the MAR goes with the patients when they go upstairs. "That makes it easier for floor nurses to see when the medication was given," says Fox. "If we happen to have a patient we haven't received a MAR on and have to start administering medications that are ordered, we have blank ones that we will go ahead and start, but we don't like to do that because it leaves us open for medication errors." |
Did you give a dose late? Document it It is bound to happen at some point: When caring for inpatients who require timed doses of medications, you forget to give a dose. "If you are caring for critical patients and taking care of admitted patients, then you have to choose between them," says Diane Fox, RN, BSN, CEN, clinical resource coordinator for the ED at St. Vincent's HealthCare in Jacksonville, FL. "If you are tied up with a myocardial infarction or pulmonary edema, the medication schedule gets pushed back on the admitted patients. We try not to do that, but it does happen." If a dose is given late, such as giving a medication at noon when it actually was ordered at 10 a.m., "ED nurses write the actual time the medication was given," says Fox. |
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