the right words

The five rights of patient medication safety include: the right person, the right drug, the right dose, the right route and the right time. It seems pretty simple enough. The last piece critical to medication safety is the right/write documentation. Not just because of the fact that if it is not documented it is not done, but if it is not documented what is stopping someone from giving the medication again.

I am continually amazed when doing case reviews at the lack of documentation. Besides the obvious legal peril that not documenting may leave someone in, the safety implications are often overlooked. And don’t forget the issue of payment and reimbursement. How can you bill for services that there is no record of? More than once I have I seen charges written off because after reviewing a medical record the “patient’s story” is not clear – there are pieces missing and the care that was provided, however appropriate and safe is brought into question because the proof is not there.

This does not just apply to nurses….physicians, respiratory and physical therapists, social workers, paramedics, and anyone who provides care to patients. A hospital defense attorney’s worse nightmare is to have to defend a hospital or provider using a chart that is missing notes and documentation. Documentation is just as important as performing the five rights.

Connect the dots. Close the loop. Write it down. Take credit for the care or treatment that was provided.

Of course, make sure what is written is both legible and spelled correctly.

Happy Birthday

May 12th, 1820 - August 13th, 1910

Nursing and healthcare have certainly changed through the years, but what hasn't changed is the impact of examing practice to improve clinical outcomes. Florence Nightingale was on to something all those years ago using science and statistics to effect patient outcomes; she positively impacted the face of nursing.

Thank you Florence.

Times have certainly changed

Perhaps it is that I can barely remember being 13 or in middle school for that fact, but I do not understand in a world jam packed full of technology such as cell phones, iPods, computers and Wii games why kids feel the need to take cold medicine to get high. Ok so I was not perfect growing up, but I was too busy in middle school going to slumber parties and the mall and the movies to wonder to myself what it would be like to take some random OTC cold remedy.

My favorite part is the attitude that accompanies these pubescent, hormone-intoxicated kids when they present to ER with a chief complaint of an overdose. Seriously? What do they honestly think is going to happen when the nurses and physicians in the ER ask them why and when and how much they took? Of course you are going to be stuck with needles and asked to pee in a cup and drink activated charcoal with Hershey’s syrup over ice! And mom, please do displace your anger towards the staff trying to undo the damage 24 cold and flu tablets with acetaminophen can do.

Then there is the burning question in my mind – What happened to stealing cigarettes and sips of alcohol from your parents’ liquor cabinet? I am not as old as you think – I was just too scared to try anything else, because my mother would have killed me if ever I got caught! But I guess the times have changed and each generation has their own sense of what is cool and the thing to do. This nurse just does not get it; but then again would I want a cranky nurse taking me after I got caught chewing cold tablets like candy or some compassion – hmmm, the jury’s still it out on that one.

Blood, bandages & bedpans

It seems a little odd that a job that almost broke me is still my most favorite. I had not realized how much I missed working in the emergency room until I pitched in the other day for a couple hours as they were bursting at the seams. Sure the very short shift consisted only of pushing one wheelchair-bound female to her family’s car, cleaning and making numerous stretchers and removing one IV. I did triage from EMS the very pleasant gentleman that was the unfortunate recipient of a head bleed. It was rather uneventful. I have missed the commotion, the noise, the smells…yes, all of them; there really is no other place quite like it.

I returned to my regular job just as quickly as I arrived to help out in the ER. It occurred to me when I was back in my very quite, feng-shui office that you may take the nurse out of the ER but can’t take the ER out of the nurse.

Counting Calories

So apparently we need an official research study to tell us that eating less calories will result in less body weight (see “Fewer calories = less weight” posted by theHeart.org). In a society obsessed with outward beauty, it is hard to fathom that over 66% of Americans are obese. Obesity is defined as being 20-25% over the ideal body weight; so why then in a time where fad diets are all the rage are there so many overweight people and even more that are perpetually dieting? There is the Atkins diet, the South Beach diet, the Nutri-system diet, the Jenny Craig diet, the Weight Watchers diet, the Slim-Fast diet, the Acai Berry diet, the Pink Grapefruit diet, the Flat Belly diet and the numerous other diets that claim to give you the stealth body you have always dreamed of. No wonder we need medical research to clarify that consuming less calories combined with exercise is the sensible way to lose or maintain one’s weight.

For me, I will happily stick to my “no meat, low fat, whole, no processed or refined foods diet” - of course until medical research proves I should be eating something else.

The birds and the...alligators?

Spring is almost here! On warmer days you may catch a glimpse of an alligator venturing out of his den and laying in the warm sun. Another tell-tale sign is the ospreys that are returning busily making their nests.

Check out the Osprey Blog and the web-cam - very cool!

http://www.palmetto.coop/community/osprey/env_osprey.asp

Happy bird-watching!

Science or circus?

It seems that the American’s always want more no matter the consequences. We as a society tend to be gluttonous and selfish; especially when it comes to food and money. But now we can add babies to the list things we need more of.

Apparently if you have more babies than nature intended new opportunities open to you. Perhaps that is the real motivation behind this mother having so many babies…all at once. This of course is in addition to her other 6 children she had previously. My question is how she paid for the in vitro fertilization (IVF) in the first place at nearly $20,000 per cycle. This is a woman who is in danger of having her house foreclosed upon and is living on food stamps and her phone has been disconnected. She has defaulted on student loans and is planning go further her education with a masters degree. How can she responsibly take care of and provide for these children when her priorities are obviously skewed? Perhaps the TV interviews and rights to the innocent pictures of these fragile babies in isolettes will provide a roof over their heads and food in their bellies.

The expense of care will fall onto the tax payers of California, which incidentally is also financially struggling. Who is going to pay for their well-baby checks and vaccinations and formula and prescriptions? What about the physical and developmental issues they may all come to bear? How can we be sure she is even able to care for these babies? And ultimately be responsible for their character development and becoming productive members of society? Clearly her judgment is impaired and making responsible decisions is not something she is experienced with.
Disclaimer: Obviously the fertility specialist is not free from blame in this situation. Abusing medical technology for personal gain is not only irresponsible, but unethical. Medicine is a science, not a circus.

Common sense, not so common

It seems with patients continually being admitted and discharged, numerous medications to give, IVs to tend to and the myriad of other tasks to accomplish, nurses have lost the ability to problem solve or think critically and in some cases use common sense. Is this a symptom of the increasingly high census and acuity of patients? Or is it something they are forgetting to teach in nursing school? Perhaps it is a combination of issues. Being a nurse today is harder and more demanding than it was 10 or 15 years ago; but if ever there was a time that prioritizing and problem solving were needed, clearly it is now.

Recently my 90 year old grandmother was admitted for a bowel resection secondary to a tumor in her ascending colon. She was a model patient. Considering her age she did remarkably well. Despite her strong recovery from surgery, she developed a few complications post-op day 2. My concerns were not so much the physiologic responses to surgery, but the way in which the nurses reacted to these changes in her condition. The inability to recognize signs and symptoms of delirium, dehydration and bowel obstruction were worrisome. It was I that assessed the changes in her mental status and realized that she was having a reaction to the Benadryl, which is known to cause acute agitation and hallucinations in the elderly. It was I that assessed her fluid deficit secondary to severe diarrhea and suggested that the physician be called to re-evaluate her labs and repleat fluids and electrolytes. And again it was me that assessed her increasingly rigid abdomen and suggested that a post-op radiological exam be obtained.

There is a paradox in nursing. We as a profession want to be viewed as intellectual and autonomous professionals, but do not want the responsibility of communication and collaboration. There is a difference between ‘bothering’ the physician with a question that can wait until rounds or a change in the patient’s condition that warrants intervention. It has not been my experience that a physician was annoyed to know that the patient’s condition was deteriorating.

Assessment, intervention and evaluation are important concepts of problem solving, not too mention part of basic nursing practice…which of course is just common sense.