Medication Error by Covering Nurse

I was recently speaking to a nurse about an incident that occurred at her hospital.  A nurse that was changing shifts asked another nurse to do her discharge teaching and administer a medication for her as she was busy.  This is a frequent thing that is seen amongst many different facilities. The covering nurse administered a medication to the patient and he had an adverse reaction to it, because it was the incorrect dose. It is a scary thought to think that this could happen to any of our families staying in a hospital or as a healthcare professional that it could happen to us.

medication

In speaking with the nurse she proceeded to tell me that the nurse at her hospital was too busy to attend to her own patient to do the discharge planning.  She could have taken the patient herself and done a proper discharge planning and allow the new nurse coming on to take care of another patient, but instead she gave the nurse coming on shift her discharge. I would hope that in this day and age a nurse would not administer a medication or explain a medication that she is not familiar with.  In talking with the nurse, I felt that the covering nurse should have verified the medication if she had a doubt about it as that is her license on the line.

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The covering nurse needed to be more information seeking and applying standards of care.  Regardless if the other nurse was busy, it is up to the covering nurse if she accepted the assignment to fulfill it correctly.  This means she needs to be able to follow the standards of care in that unit (Rubenfeld & Schaeffer, 2014).

 

References

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

Quality and Safety at Well Baby Clinics

Recently, I was speaking with a health nurse at a clinic about the increase in babies being sick due to a lack of well baby check ups and vaccinations.  In speaking with the health nurse and in review of her concerns about her well-baby clinic, one of the critical dimensions that came to mind was inquisitiveness to determine whether offering immunizations at her clinic was working or not working to get the parents to come to the clinic.  If it is a well baby care clinic, are the parents bringing in the babies for any other check ups? For instance  are they coming in when a shot is not needed?

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After our conversation, the health nurse decided to seek information about the mothers that were not coming and noticed that there was a drop in the amount of people who came because they did not have public transportation available for them, due to the distance that they lived from the clinic (she is in a rural area).  I suggested that there should be some creativity on the clinic’s part to establish a new way for the immunizations to get to the parents.

immunization

Creativity and inquisitiveness were two critical thinking dimensions that I identified in this well baby clinic scenario as I was speaking to the health nurse.  The structure is the routine immunizations that they provide to the parents at the clinic.  The process is based on the age of the infant and that will determine when they come in for their routine immunizations.  The outcomes are the hopes of reducing childhood illness, for instance measles (Rubenfeld & Scheffer, 2005).

In thinking, there are a few alternative ways that I think would help the well baby clinic and also help these families. First of all, finding out where the majority of the families that were affected by the lack of transportation live.  Once that is determined, locate a school, church or shopping center that will allow once per week or once per month depending on the amount of babies that need immunization, to set up an immunization clinic for those families affected by the bus system.  The schools, church and shopping centers are places that parents will need to go to if they have school age children or if they have to buy groceries or attend a church.   Even if they don’t attend the church, if it is in the community they have easy access to bring the baby for the immunizations.

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Another alternative, is working with the resources available in the community.  Perhaps the clinic can find out if the transportation available to take people to doctor’s appointments would be available to bring the parents on a specified appointment day.   If the bus can pick up the parents where they used to take the city bus and bring them in to the clinic to get the shots, then go back to the bus stop once the group was done.

bus

When the clinic presents these alternatives to the stakeholders making the decisions on what they will pay to make the clinic a success, it is important to share the benefits for doing the immunizations.  If presented in a narrative format, explaining first, the subpopulation that uses the clinic, then the treatment and frequency that they come as well as the consequences of the parents not coming.   Presenting the stakeholders with realistic facts if the babies are not immunized and that they can get a childhood illness like the measles, and how an epidemic can spread in the community, is an eye opener.  If there are complications from the illness without having proper care to the child or even an adult who was never immunized as a child, there can be an inpatient hospital stay.  The inpatient hospital stay would cost the tax payers and stake holders more money when simpler solutions could have been implemented.

In conclusion, education and preventative care is the basis of the well-baby clinic, but when the parent does not have the means to get to the one and only clinic, then an alternative to provide the same service has to be sought to keep the community healthy and avoid unnecessary inpatient hospital stays.

 

References

Rubenfeld, M. G., & Scheffer, B. K. (2015). Critical Thinking TACTICS for Nurses:Achieving the IOM Competencies (3rd ed.). [Vital Source BookShelf]. Retrieved from http://online.vitalsource.com/books/9781284059571

Implementing Changes in the Emergency Room

An emergency room nurse asks how can he make changes in his emergency room to better serve the patients?

My response to the ER nurse was to acknowledge that I understood his enthusiasm in wanting to make the changes in his emergency department. In such a fast paced department where it is a matter of life and death,  it is hard to implement changes because the nurses may feel they do not have the time to learn but as managers we know that a change must take place (Stevens & Caldwell, 2012).  The emergency department is one of those places where there is never a happy medium making it difficult to staff and do trainings.  But as the website for the American Academy of Healthcare Communication noted “communication is the key to exceptional patient care” (http://www.health.gov/communication/resources/Default.asp).

emergency-room

In order for the nurse to feel that there needs to be a change, there has to be an explanation to them impressing that remaining in the same pattern is not helping the patients.  As managers though, we need to be careful on how this is communicated to the staff, because people are sensitive and if they feel that the work they are doing at the moment is not good enough, they will not accept new changes favorably.

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One way to implement change is by communication in a narrative format;  doing a synopsis of what has been happening in the emergency department.  For example, how many patients have had complications as a result of starting an IV on patients with difficult vascular access because too much time was spent on trying to get an IV line in or calling someone else when attempts have failed?  Without laying blame on anyone,  if this study is brought as a statistic and narrative then it may help the nurses see the importance of a quick ultrasound to see the access.

Everyone is always afraid of change but if presented in such a format where they are given the time to learn it, for example paid education to come to the training on an off day with different options given for the training based on the two or three shifts that the hospital has.  Once the plan is implemented for training, being able to have the educators follow-up with each nurse on how they are doing, will show the staff that the management genuinely cares.  It is important to know if the new transition towards the change is working and if not why, so that the training can be revamped.

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Once the nurses see that the change is going to make their jobs easier and the patient’s quality of care rises to a new level, they will be more receptive.

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References

Stevens, K. R., & Caldwell, E. (2012, August 29, 2012). Nurse Leader Resistance Perceived as a Barrier to High-Quality, Evidence-Based Patient Care. The Ohio State University Research and Innovation Communications. Retrieved from http://www.health.gov/communication/resources/Default.asp

Communication Resources

As a nurse leader, one has to be able to communicate with the staff and the patients as well.  Nurses are influential in informing people about changes that will affect their health (http://www.health.gov/communication/resources/Default.asp).   Patients do not like change, much like we do not like change.  In order for you to make an impact on someone to change, the person has to be able to feel that remaining the same will be more painful physically or emotionally than making the change itself.  For example, the patient that is a diabetic but insists on eating the wrong foods because they like cookies, cake, ice cream and soda, has to be willing to want to make a change.  The obvious change that we want to see is that the patient follows a diet and exercise routine to maintain his diabetes so that he can avoid elevated blood sugars and all the other complications to the body that come from elevated blood sugars.

Senior Couple Studying Financial Document At Home

Sometimes the assistance of oral agents to control the blood sugar is necessary. The painful alternative to not stopping the inappropriate diet would be, monitoring blood sugar four times a day and administering insulin on a sliding scale.  The pain of needle sticks and frequent trips to the doctor to manage the diabetes may be an incentive to the patient to follow his diet.

diabetic

Now on the management side of things, just as communication is going to be the key to our patient accepting change, this is also true for employees.  In a previous position, change was always happening.  We were dictated and told that the change was here and it was happening effective yesterday as the expression goes.  As managers we were to accept it, implement it and move on to the next thing (Stevens & Caldwell, 2012). The employees were kept in the dark and not given much information except to say that the change was here and it had to be done to perfection.  An example was a company department goal that was added to the staff evaluation was to have zero mistakes on any reports based on the staff doing their work one hundred percent perfect with no margin of error. It was an unattainable goal as no one in this planet is perfect.  The staff was never made aware of this goal and how it would be tied to the financial aspect of the company.   If the employee had one mistake this would affect whether they obtained a bonus or a raise.

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When I was in a leadership position, my leadership with my team has to be such that I could be and  influence to them in a positive way and be able to help them  grow and embrace new changes.  This was not an easy process for me as I always try to be there for my staff, but there is no one there for me.  I opted not to be a transactional leader to my team.  I opted to be a transformational leader that will help their team grow in the long run.

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References

Stevens, K. R., & Caldwell, E. (2012, August 29, 2012). Nurse Leader Resistance Perceived as a Barrier to High-Quality, Evidence-Based Patient Care. The Ohio State University Research and Innovation Communications. Retrieved from http://www.health.gov/communication/resources/Default.asp

Rapid Changing Healthcare System

In our rapid changing healthcare system, it is very important to be able to have information at the tip of our fingers so that we can best help our patients.  How great it is to have the patient’s medical records available after entering their information in the system when the patient asks a question.  My favorite thing about having the patient’s information at your fingertips, is when a patient calls me, to help me remember them I always jot down some personal information about them; for example, one patient loved to watch her Spanish soap operas, another had a pet bird named Sam.  Knowing these trivial things helps me build a relationship telephonically with the patient, this allows me to ask about it so that when it comes time to discussing their healthcare and goals, I have established a trust to build a stronger effective care plan.

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Critical thinking needs to be incorporated in to the informatics process.    Through critical thinking and informatics, we are encouraged to consider our own needs, have positive feedback and think logically to assist us to make good decisions that are based on evidence rather than on emotional feelings (Rubenfeld & Schaeffer, 2014).

References

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). Retrieved from http://online.vitalsource.com/books/9781284059571

Implementing Changes

Many nurses ask themselves, how can we as nurses implement changes in our units and departments?  One way to implement change is by communicating in a narrative format; doing a synopsis of what has been happening on our unit or department.  For example, how many patients have had complications as a result of coming in with an ulcer to the unit vs. the ones that may develop them in the hospital?  Without laying blame on anyone, if this study is brought as a statistic and narrative then it may help the nurses see the importance of proper documentation on initial admission.

nurses-making-a-change

Everyone is always afraid of change but if presented in such a format where they are given the time to learn it, for example paid education to come to the training on an off day with different options given for the training based on the two or three shifts that a hospital or facility has.  Once the plan is implemented for training, being able to have the educators follow up with how each nurse is doing, will show the staff that the management genuinely cares.  It is important to know if the new transition towards the change is working and if not why, so that the training can be revamped.  Once the nurses see that the change is going to make their jobs easier and the patient’s quality of care will be raised to a new level, they will be more receptive.

nurses-making-a-change-2

References

Stevens, K. R., & Caldwell, E. (2012, August 29, 2012). Nurse leader resistance perceived as a barrier to high-quality, evidence-based patient care. The Ohio State University Research and Innovation Communications. Retrieved from http://www.health.gov/communication/resources/Default.asp

Best Practices for Informatics

The informatics that is available to nurses is amazing.  Although there is always going to be something that someone thinks of that will improve the quality and speed of how we do our jobs,  we as nurses have to be willing to have intellectual integrity that moves us beyond our own needs (Rubenfeld & Schaeffer, 2014).  I used to work remotely from home as a manager for field case managers.  Our case managers would go out in the field and see the members on our health plan. They carried a laptop so that they could document anywhere and pull up their member’s information.  Of course the security to get into the laptop was only via an ever-changing token so that they could access it. With protected health information, the nurses had to be extremely aware of technology.

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Years ago, many nurses had to document on paper when they would visit a patient in their home and they carried a paper chart in their car.  Informatics has improved in leaps and bounds.

laptop-in-car

When the case manager is at the member’s home, they are able to do their assessments right in the member’s home and share the outcome from the assessments with the member.  Meetings were held via WebEx when we had them because everyone worked from home. This made training on a new process easier giving everyone the ability to receive new information at the same time.

Female doctor visits elderly woman patient in nursing home. Laptop.

We also had a patient interface after the member was enrolled in our program.  The member would get in the patient status screen and would be able to add goals to their plan of care that they wanted to work on.  When the member filled this out, the nurse on the file would receive an alert that someone updated their file.

Close-up of happy female doctor talking with senior patient at clinic.

I see many opportunities for transforming knowledge from the use of informatics.  For instance if we were able to send doctors an email right from the member’s file, and get the reply from them instantly, it would cut back on the time and phone calls to doctors to get certain forms filled out for the teams throughout.   Some nurses that did not grow up with computers may have a challenge adapting, but with some education that can be done right from WebEx, they can learn.  Computers and their programs are not going anywhere; they are the wave of the future.

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References

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. Retrieved from http://online.vitalsource.com/books/9781284059571

Culturally Competent

In today’s world, there needs to be more education of staff on diversity of cultures.  In healthcare it is very important to have all staff, not just nurses, be aware of the different cultures that come in to the hospital, nursing home, rehab centers and doctor’s offices.  Health and illness are looked at in many different ways by different cultures. Take for instance the Hispanic population; it is one of the fastest growing ethnic groups in the United States.

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There are many health risk factors in the Hispanic population.  Some examples of health risk factors are smoking, uninsured under the age of 65, diabetes, diet, hypertension, obesity and low birth infants. There are also many causes of death seen in the Hispanic population for instance, heart disease, cancer, unintentional injuries, stroke, diabetes complications, chronic liver disease, homicide, influenza, pneumonia and disorders originating during pregnancy.

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Hispanics are challenged on a daily basis because they have environmental and community risk factors as well.  This group has limited access to healthcare, problems with immigration status, language barriers, cultural barriers, lack of preventative care, and lack of insurance and dangerous work conditions at times.

As nurses we need to be able to provide culturally competent care to our patients. At times rather than just going through the motions of medicating patients, we need to process the information that we are receiving. There are several strategies that we as healthcare workers can use.  The first strategy in assuring culturally competent care should be evaluating the healthcare professional’s individual approach to the culture that is being worked with by asking yourself questions. Am I aware of my own biases and prejudices towards the group I am treating? Do I have the knowledge and skill to conduct the assessments that are needed in a sensitive manner?  Do I seek out to interact with other cultures other than the ones I am comfortable with?  Do I really want to be culturally competent?  (Jeffreys, 2008) Another way that nurses can become more culturally diverse is by gaining the patient and family’s trust.

References

Jeffreys, M. (2008, November/December). Dynamics of Diversity Becoming Better Nurses through Diversity Awareness. NSNA Imprint, 36-41. Retrieved from http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Imprint_NovDec08_Feat_Jeffreys.pdf

Critical Consciousness

My awareness of critical perspective has expanded beyond the arena  of where I work, it has involved my charity The Gift of Life  and my wedding business 27 Miracles.  I started out my nursing career working in a high risk labor and delivery unit.  In labor and delivery you meet all kinds of people from different walks of life, different religions, different ethnicities and socioeconomic status.  During a critical time such as labor when there is pain, this is when you learn about other people’s cultures and how pain is perceived by them.  As a nurse we learn about those different cultures through experience so that when we do encounter them, we can understand what level of privacy and respect they need.

parents-in-labor

My husband and I own a wedding and event planning business called 27 Miracles.  Through the years we have become well known in our town for working with ethnic weddings from different countries as well as interracial.  It has allowed me as an individual to learn many cultures and be able to show respect for other cultures and their ways of communicating.  It is a beautiful thing to see love spoken and expressed in so many different languages and cultures through music, food and traditions.

wedding

I have learned through my nursing experiences and my wedding experiences how to appreciate people more and take interest in who they are as a person.  As nurses we get  busy when we work on the floor or in an office and talk about our patients as just another number because we are  in a hurry.  Even on our busy days, we need to stop along the road and take a moment to say hello to our patients, provide a gentle touch to their hand or shoulder, and a listening ear.  These are all part of critical perspectives or as I like to call it cultural awareness.

Nurse holds elderly patient's hand

Many say that the parents of premature babies experience preterm birth  because the parent did something wrong, they smoked, drank, did drugs or a teen age pregnancy caused the premature birth.  Although some of those reasons may be true, there is another side to prematurity that people do not think about.  The mother that develops maternal illnesses like Diabetes and Hypertension, or the baby that for some reason starts developing intrauterine growth retardation and it is unsafe for him or her to be inside the womb.  It is very easy to judge when you don’t know the situation or have never experienced it, but as nurses we need to develop  ways of thinking that allows us to be aware about ourselves and those around us  (Gotzlaf & Osborne, 2010).

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Working with a population of parents that have premature babies, has shown me that premature birth happens all over the world. Premature birth limits no race, religion or economical status.  Our job as a nurse is to be aware of the different cultures and take the time to learn about their culture and how you can work with that person.

new-moms

References

Gotzlaf, B. A., & Osborne, M. (2010). A Journey of Critical Consciousness: An Educational Strategy for Health Care. International Journal of NursingEducation Scholarship, 7(1), 1-15. http://dx.doi.org/ 10.2202/1548-923X.2094

Working Your Staff Unsafely

This week has been the week of speaking with different professionals on training and how companies place employees in jobs that are not properly trained in their skill set to pay them less and get more out of them.  I used to work for a large insurance company that employed over 80,000 people.  I worked in the long-term care department which had about 400 staff from administrative assistants to presidents. I was the manager of case managers which consisted of RN’s, LPN’s and Social Workers.  They all did the same job and got paid different salaries to do it, however the job description and responsibility was the same.

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I felt that this policy of having nurses and social workers working on the same cases needed to be changed. Having all the staff doing the same exact work and paying them differently based on their degree and expecting the same level of skill, was inappropriate.   Nurses have a different skill set than social workers.  If a patient has a medical issue, the social worker that is visiting that member in the home completing an assessment may not be able to capture that the member has been retaining water in their ankles and think to ask if they are on a diuretic.  Much like the nurse that goes in the home setting and sees a patient that has issues paying their light bill won’t know where to call to find a resource for them.  The patient may be concerned because they are on oxygen at home; they wonder how they will pay their light bill and what they will do if the power is turned off. This can be a liability to any staff member but also a disservice to the patient.

oxygen

In contrast, I worked for another company that did case management. I loved that job, until federal cutbacks came along for the program during the new Obama administration.   The company employed RN’s, MSW’s, CHW’s, Nutritionists and Behavioral Health Specialists.   The cases were assigned only to nurses and there were two tiers of nurses, regular case managers and those that were more experienced received complex care patients.  The other staff MSW’s, CHW’s , Nutritionists and Behavioral Health Specialists were consulting on the files that the nurses referred to them.  They would work as a team with the nurses. This team work gave the patient a more well-rounded form of care.

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There are several leadership styles in companies, autocratic, democratic and laissez-faire.  In the large insurance company that had all the workers regardless of skill set do the same job,  the leadership was autocratic.  The department maintained total control in all decisions and no opinions or suggestions were accepted from others. There was no opportunity to make a change due to the leadership style.   In my prior job, where everyone worked on a tiered team,  there was a democracy; decisions were made after consideration of input from the staff (Mitchell, 2013).

A team of medical professionals  gather for a daily meeting to discuss the elderly patients at the “Acute Care for Elders” unit at the University of Alabama Hospital, Birmingham. (Hal Yeager for KHN)

There are some days that as a professional you want to see changes implemented or at least considered, however the leadership does not support that.  If you are the type of person that works for the better of seeing changes in a situation, get involved in the departments or committees that have a say in policy writing, this will be the only way to see changes that can be discussed for the betterment of the company.

References

Mitchell, G. (2013, April). Selecting the Best Theory to Implement Planned Change. Nursing Management, 20(1), 32-37. Retrieved from http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?sid=4ba42c53-9a6d-4ec5-b6bb-2f078e04b7c7%40sessionmgr4001&vid=1&hid=4204