October 21, 2007, 2:04 pm

You Don’t Really Wanna Mess With Me Tonight

maddoctor

I’m not sure how mad the doctor is in this film, but it’s Basil Rathbone!!!!

I love Basil Rathbone!

There has never been a better Sherlock Holmes on the screen.

Hands down!

Suave and sinister! My kinda guy!

******************************

Medication reconciliation forms.

Every time I fill one out I have every four-letter-word known to man run through my brain and then I invent some new ones.

And last night it got worse.

Pardon my language, but I am pissed off. Royally.

*****

Let me do a quick recap of what we are required to do, as nurses, on the medication reconciliation form:

  • We are required to write down precisely what the patient tells us, even if we know it is the wrong dosage! If the patient says they take 25 mg of Ativan every four hours, we have to write “Ativan, 25 mg” on the reconciliation form.
  • If the patient hands us a list of their medications and instead of “Furosemide”, they have written “Furobedide” we have to write it exactly as it is printed on the list!

Now, the paper that we so painstakingly fill out in our ER is then taken upstairs with the patients that are admitted and all the admitting doctor has to do is look at it and check off the box if they want it ordered in the hospital.

Did you get that? We nurses write the orders out in their entirety and all the doctors have to do is CHECK A FREAKING BOX.

Sorry, I’ll try not to shout.

What this means is that (1) the patient is actually writing their own orders based on what they tell the nurse on admission when (2) the admitting physician should be responsible for finding out exactly what the patient is taking and write their own orders!

*****

So what’s new, you say? Same old stuff we’ve (I’ve) been writing about ad nauseum for the last year? Yadda, yadda, yadda?

Hardly.

I walked into work last night to find a note on the bulletin board (this is the preferred method of communication where I work) telling us that Dr. Q found a dosage error on a medication reconciliation sheet that would have “sent a patient to ICU” and that we nurses in the ER needed to be more careful.

<commence seething>

It gets better. Attached as an afterthought was a post-it note stating Dr. Q also thought that the floor nurses should go over in detail everything that is written in the ER after the patient gets up to the floor. Oh….and he appreciates all our hard work.

<full seethe ahead>

I left a choice note on his note and I am too old and too cynical to give a damn about the repercussions.

*****

So this week’s theme for Grand Rounds is prognostication.

I foresaw this trouble looooong before now. The way we are required to fill out the medication reconciliation sheet is a safety hazard. It has been, it is now, and it will continue to be.

It is the rare patient who knows exactly what they take, how much they take or why the hell they even take it!

But this is what their orders are being based on.

Even if they come in with two full pages of medications, single spaced and printed off a computer, when I verify the meds with them there will be 3-4 changes and at least three that have been discontinued.

So now the ER is getting criticism while doing something the doctor should be doing to begin with, but that is not the worst part.

*****

The system is set up so that any discrepancy, any dosage error, any transcription error (we aren’t allowed to xerox the patient’s list) – any adverse reaction/incident….can be blamed on a nurse for writing it “wrong”.

Yet they require us to write it “as is”.

The system is set up to fail. Somewhere, somehow, someone is going to be hurt. And I’m not exaggerating when I say it will be the nurse whose signature is on the bottom of that form that will take the fall.

So, Dr. Q, before you come down and spread your eminent wisdom to those careless emergency department nurses, why don’t you find out why that dosage landed on your patient’s form, realize that you should be ultimately responsible for what is ordered and then thank us for doing your job.

Don’t criticize us on one hand and then patronize us with your appreciation of how hard we work.

You don’t have a clue, buddy.

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25 Comments

  • Rae
    Rae

    October 21, 2007 at 2:46 pm

    We had a similar problem at my institution when we first started med recon, but the system is much improved–there is a software program that keeps “home meds” in a print-out form that we are responsible to print out & ensure the MD receives a copy. The MD can then check off the meds they want the pt to continue receiving, and write in new ones as well. Docs were forced to do this because the pharmacy won’t send ANY meds until the form is filled out. (Believe me, even though it was on a PREPRINTED form we had some difficulty with this for a while) This handy form is also re-printed again on discharge. Med Recon is supposed to make the system safer–and I agree, the nurse should NOT be writing out the pt’s home meds to be kept on records. We don’t prescribe!

    I think your institution should take responsibility to make this system safer. JCAHO would have a fit with this.


  • Nurse K
    Nurse K

    October 21, 2007 at 2:49 pm

    If a patient takes an obviously incorrect dose of a medication (a lot of times they’re obviously guessing), we can write the name of the medication and “unknown dose” and/or “unknown frequency”. I’d rather just write unknown dose and have it be confirmed than write something that is obviously incorrect. We have to sign off whether or not the medication review is “complete”. If I have anything that is “unknown” then I can say “no” and people will be forced to go back and fill in the blanks. If I just write all the medications in with their made-up dosages and sign off “complete”, it seems that I wouldn’t be doing my job.

    For the clueless, you can always try their pharmacy. Everyone can remember what pharmacy they go to.


  • NPs Save Lives
    NPs Save Lives

    October 21, 2007 at 2:53 pm

    That sounds like a pretty dangerous situation for everyone involved. I agree that many patients don’t have a CLUE about what medications they are taking or what for. The list should be as complete as possible and looked at by the ER doc as well as the admitting physician to ensure accuracy. Stop blaming the nurses for the inadequate patient that is occurring outside the hospital. JEEZ!


  • Caroline
    Caroline

    October 21, 2007 at 6:06 pm

    That just sounds STUPID. I have no words of encouragement here because…well, that’s just stupid!! When are the hospitals gonna learn? Sigh.


  • medrecgal
    medrecgal

    October 21, 2007 at 7:13 pm

    Wow, how messed up is that? They expect patients to know exactly what they take and at what dosages, and then there can be no correction based upon a nurse’s clinical knowledge? Isn’t that kind of bass-ackwards? I’m sure there are plenty of well informed patients out there, but I’m also sure there are a good number who don’t have the foggiest idea regarding the types, dosages, and proper spellings of their medications. Nurses should be allowed to edit that information based upon discussion with the patient, the contents of the medical record, and information possibly provided by any involved MDs. For it to be any other way is inviting trouble, IMHO. Sounds like the med recon form procedure needs some editing!


  • Beth
    Beth

    October 22, 2007 at 4:30 am

    That is really just beyond stupid that you are required to write down wrong med doses and then are held responsible for the error of it. Has your nurse manager done any kind of advocating to change/improve this policy? I would refuse, but I also like Nurse K’s idea of writing down “unknown dose” if you know that it is an impossible dose.

    It’s funny that the docs go along on this one. Sure it’s one last “task” that they have to do but with such a misunderstanding of what the nurses are required to write down, they are destined to miss a fatal mistake as well.

    Who exactly is running your hospital? Mickey Mouse?


  • Mother Jones RN
    Mother Jones RN

    October 22, 2007 at 5:39 am

    It sounds like you have a two-fer going on at your hospital.
    Stupid JCAHO + stupid hospital policies = dead patients. And yes, you are right. A nurse is going to take a fall.


  • mumkeepingsane
    mumkeepingsane

    October 22, 2007 at 6:28 am

    Wow, that is ridiculous. I am very concious of what everyone in the family takes dosages and all but I know I’m in the minority in that respect. And I could still make a mistake when I’m ruffled (which I’m guessing I would be in the ER).


  • Heidi
    Heidi

    October 22, 2007 at 7:24 am

    Hi Kim — I’m sure you’ve already tried to raise this issue with the powers-that-be at your hospital, but the way you wrote it here makes it so obvious what the problem is… perhaps it should become an e-mail/letter to administration?


  • MyOwnWoman
    MyOwnWoman

    October 22, 2007 at 8:50 am

    I trust my family’s medication list or my own to no one….especially in times of crisis. Each family member gets a list of medication with the correct information. On the top of the list, there is even a date when I updated the med list. There is a section on the paper that lists what medications have been deleted, when and why, and why any new medications were started. I don’t do this because I think the ER nurses are idiots; quite the contrary. I’m an ER nurse who LOVES medication lists. It helps with the history in addition to knowing the med.

    I can’t tell you how many times I’ve been told… “I take that little blue round pill, you know what it is, it’s suppose to calm my nerves.” Hey Patient, you got any extra of that for the staff???


  • Juliamd
    Juliamd

    October 22, 2007 at 12:59 pm

    I know what you mean, Kim. We did the same at my hospital only as the physician, I was the one signing that the list was true, accurate and complete. We raised heck with them, saying that no way were we signing off on that and neither should the nurses! The form was redesigned so that it just says that the info was received and who gave it. You absolutely need to let admin and Pharmacy know so that they can redesign it. That doc is also absolutely in the wrong because YES that is the doctor’s responsibility for verifying meds on admission and guess what? there was an error (I’m not saying the nurse was wrong, only that the dose was wrong)- that is the purpose of these forms.


  • nocturnal RN
    nocturnal RN

    October 22, 2007 at 1:17 pm

    That is just STUPID! Who made up that rule?


  • Tom
    Tom

    October 22, 2007 at 3:37 pm

    ? what is the exact problem that this process improves?

    The person least likely to know exactly what/why/when and how much (other than 1 or 2 or 3) of a specific medicine they take is the presumably sick patient in the ED.

    So, the least likely historian, gives information that must be written down exactly, even if incorrect, by the nurse, to make it easier for the doctor, who will most likely think the nurse is an idiot for not spelling medications correctly…. oh well, I hope I don’t meet the committee that thinks this process is something the IOM would approve of!


  • DixieLaurel
    DixieLaurel

    October 22, 2007 at 5:18 pm

    One of my “favorite” thing about the med rec form was that often there would be no dosage, route and or frequency for the patient’s med and the docs would just check it off. Then when you call them to get the correct information they get all pissy because they were “just about to eat dinner” or whatever.


  • geena
    geena

    October 22, 2007 at 9:01 pm

    If the doctor is check-marking the box, he/she is in effect agreeing to what is written there.

    If Furbebibe 360 q day is written, and he checkmarks it… guess what. He just ordered it.

    I can see how a nurse could take the fall for “transcription error,” but ultimately it is the physician who signs off on it.

    Or did I read your post incorrectly?


  • Mon
    Mon

    October 23, 2007 at 1:51 am

    And I hate them too because they cant write legibly. I remember a hospital where the doctors write their orders as if sketching grasses in a meadow. That’s why I had to listen really carefully and jot down my own notes while they visit their patients and make orders.

    What will the patients do without nurses.


  • ali
    ali

    October 23, 2007 at 4:59 am

    we have a med reconciliation computer system-it is supposed to part of the admission to the floor, the ed doesn’t do it. the problems i have experienced are very much the same
    1)the patient doesn’t know what they are on, what the dose is, or why they are taking it,
    2)if they have a list with them it has changed since they wrote it all down-and i have seen meds ordered based on that list and the pt put back on meds they had discontinued for a reason-and suddenly they are tachy, brady, confused (again) until someone comes in and says we stopped this med for this reason.
    3)in our institution if we actually do go into the computer and type out the med list the physician can carry that list over into the order screen, except they don’t, they just go in and enter their orders and don’t bother to cut and paste. now at discharge the paper work does carry over the med list so one section says take only these meds and lists what the doctor puts in, the section immediately below it says do not take these meds and takes the orders from the med recon. list that the doctor did not order. so it ends saying not to take the same meds in the section above it says to take. then we have to go to a patient to give discharge instructions and tell them to disregard the do not take section. all in the name of having a safer system so patients are aware of what meds they should be taking!
    my solution-i don’t fill out the list in the computer-it was presented to us that the doctor should do it, and nurses were to add if the md missed something-but if the md didn’t do it we should. i haven’t gotten in trouble yet anyway, and i know i’m not the only one not doing it!


  • Sally Plumb patient
    Sally Plumb patient

    October 23, 2007 at 5:14 am

    Hi!
    I am an nhs bi- polar patient. For over 30 years I have been prescribed largactil. Now I am suffering an awful illness–tardive dysathenia.It is crucifying and irreversible and caused by an excess of the drug.Be careful I beg of you.
    Regards Sally PLumb


  • LibraryGryffon
    LibraryGryffon

    October 23, 2007 at 7:10 am

    When I was a unit secretary in Virginia, we had to put the orders into the computer, and if a doc wrote “IM or IV q6″, we were to put it in both ways as two separate orders. Of course the standard times for IM were 3 and 9, while for IV it was 6 and 12.

    This goes through 3 shift chart checks, AND a daily chart check, before the new-to-the-hospital nurse gives the drug both ways. And we were both written up for it.

    I asked if I had put the orders in the way they insisted we do it. Answer: “Yes”. If I’ve done it the way you want me to do it, don’t blame me if there is a screw up further down the line because of it. After that I took to adding as a notes to the orders, but that wasn’t required or even encouraged.

    And the hospital wondered why morale wasn’t as good as they’d have liked.


  • Spook, RN
    Spook, RN

    October 23, 2007 at 11:18 am

    [quote]If the patient hands us a list of their medications and instead of “Furosemide”, they have written “Furobedide” we have to write it exactly as it is printed on the list![end quote]

    My entire med-rec sheet would look something like this:

    “I take 2 white pills in the morning.
    A little yellow capsule at lunch
    The same two white pills in the evening along with a big white pill, a little pink one and a green capsule at bedtime”

    Admin can come and sign off on that list if they care…


  • terri c
    terri c

    October 23, 2007 at 9:57 pm

    The procedure as described is a procedure of such breathtaking lunacy that it could only have originated in management. You KNOW they are tracking some metric that says, number of med lists recorded in ED, and the more the better.


  • Candy
    Candy

    October 24, 2007 at 9:33 am

    Kim, your hands are tied (but you can still kick some butt with those unrestrained feet!)

    It’s a given that 95 percent of patients don’t know what they take by name, let alone the dose. Since PCPs are generally prescribing the meds, maybe they should be giving each patient a list of meds. Better still, an across the board patient records system, accessible by all healthcare providers, with current (and past) meds, diagnoses, treatments and other pertinent information.

    Oh, wait — that would mean sharing across healthcare systems… and it still doesn’t solve the problem of the nurse being the point person for everything!

    And about this: “For the clueless, you can always try their pharmacy. Everyone can remember what pharmacy they go to.”

    Since when do ER nurses have time to call a pharmacy to find out what Mr. Jones or Mrs. Smith takes?


  • melissa
    melissa

    October 25, 2007 at 7:09 pm

    Lol at Spook, RN. How true that patients know pills by their size and color and expect us to know exactly what they are talking about.

    Your hospital sounds like it wants to make sure that all lawyers are fully employed.


  • Stalwart Hospitalist
    Stalwart Hospitalist

    October 26, 2007 at 2:31 pm

    I head up the medication reconciliation task force at our medical center.

    We decided early on that the medication history responsibility should fall on the shoulders of the admitting physician, since they have to document it in the H&P anyway. We simply carved the med section out of the H&P form and moved it to a med recon form.

    We ask the floor nurses to verify that the MDs have ordered the home meds that they say they will (the form asks them which will be continued as an inpatient).

    That said, the patient is often in a better frame of mind to give a history six or eight hours after presentation, and we do ask the nurses to verify the medication history and augment it if appropriate.

    Medication reconciliation has been foisted upon us by The Joint Commission, and the “garbage in-garbage out” phenomenon is indeed rampant, but there are so many medication errors made at the transitions of care that the concept is a good idea.

    Last point — the ED is the WRONG place to try to perform med recon for patients being admitted. Too much craziness going on.


  • Alice
    Alice

    October 27, 2007 at 9:30 pm

    Kim – For what it’s worth, I love the med rec sheets. The nurses at my hospital aren’t forced to write down obviously inaccurate things; they can put unknown dose or schedule, and sometimes they do in fact write “2 blood pressure meds” or “1 sugar med.” That still gives me something to work from, saves some time, and can be tremendously useful when the patient’s mental status deteriorates between when they see you in the ED and when I see them in the ICU. But we have computerized order entry, so every medication I order is completely my responsibility, not just checking off a nurse’s list.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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