From The Floor
Mistakes Observed on the Nursing Floor
Making room for improvement
When you are the patient, or your loved one is in the hospital, you see everything the nursing staff does through the prism of experience. While most nurses provide excellent care, sometimes you may notice mistakes being made. So, as a quick skills refresher, this month’s column is about some recent experiences I’ve had or that have been shared with me.
Discharge planning begins upon admission
Somewhat of an oxymoron, but a nurse should always remember that discharge planning begins when a patient is admitted. Some hospitals have easy-to-follow discharge planning forms, while other hospitals seem to put everything short of the kitchen sink on one piece of paper. Regardless which process your hospital uses, don’t forget to focus on this as you do your daily note-taking tasks.
Discharge planning isn’t just rote work. When you prepare your patient to go home, you just don’t hand over forms and rattle off instructions like you’re throwing a bunch of spaghetti at the wall hoping it sticks.
Patients going through the discharge process need to show that they understand the instructions. Be sure that you have the patient repeat back the information you’ve just covered. This ensures that they comprehend what you’ve told them, and if they make an error you can correct it before they’re sent home.
Going through the discharge procedure thoroughly helps minimize the possibility that your patient will be readmitted.
You may find that some of the discharge forms need an update. For example, I recently came into the possession of a discharge form that instructed the patient to be sure to use latex gloves when changing their dressing. This is a hospital that’s converted to the use of non-latex to help minimize sensitivity issues for both the healthcare team and patients alike. So when I read this discharge form I knew it hadn’t been updated in a very long time.
When a patient brings medication from home
As hospitals have moved more towards the “client-based” concept of care, nurses have seen a shift in how patients expect their room to be “done-up” during their hospital stay. This means bringing more personal items from home. A nurse may now see patients who pack not only a favorite book, but their iPad, iPod, pictures of the family, their favorite pajamas, pillows and various other “good luck” paraphernalia.
But what about the patient who brings their medication from home? Most hospitals have policies and procedures that address personal items, including medication. These policies may differ from hospital to hospital, but not from nurse to nurse. Meaning that all the nurses in one facility should be following the same rules. It is generally the nurse’s responsibility to have knowledge of, report and record when a patient brings in medication from home.
Some hospitals require that all medication be dispensed from the in-house pharmacy and will ask the patient’s family to take any personal medication home. The patient may think that this is one way a hospital can “jack-up” the bill. However, there’s a sound reason for such a policy, namely knowing the provenance of the personal medication. There is no way to be sure that the medication in the bottle is indeed the correct medication and that it hasn’t been tampered with.
This policy also reduces the chance of medication being given that is contraindicated. Imagine, what might happen if a patient who is on blood thinners to minimize throwing a clot after joint replacement surgery decides to pop an aspirin or two that they brought from home to take care of that pesky post-operative headache.
Some hospitals do allow for patients to take their personal medication, generally requiring a written order. The nurse would then collect and deliver the medication to the in-house pharmacy for inventory and verification. In some hospitals the medication is then dispensed from the pharmacy, while in others it’s locked up in the floor’s Pyxis (or other similar) medstation and dispensed as prescribed. I understand that there are even some hospitals that allow for medications to be literally kept at the patient’s bedside.
Whichever system is used, there should be a clearly-written policy that outlines the process and nurses in turn should follow that policy precisely.
De facto vs. written policies
Picking and choosing which policy or procedure to follow is what often gets nurses, physicians and hospitals into trouble. The set of documents that describe an organization’s policies for operation and the procedures necessary to fulfill those policies are developed in response to external forces. Federal, state, county or city law mandate regulations, as do state medical and nursing boards, along with oversight bodies, such as the Center for Medicaid Services (CMS), the Joint Commission (JCAHO). One example of a state law governing nursing policy is California’s nurse/patient ratio law or Title 22.
All this makes for a tangle of regulations and laws that can make a person’s head spin. These voluminous documents are not there to make life miserable, but to help shield us from our own “never” events. Which is why, when in doubt, a nurse should always refer to the hospital’s policies and procedures. Today they can usually be found in electronic format, making access and searching easier.
Policies and procedures are subject to human foibles and failings. The most common is the lack of enforcement. For example, let’s say the hospital allows patients to take their own meds if there’s a written order stipulating such, but over time physicians and nurses have become lax about logging in, inventorying, and securing the medication in either the pharmacy or the medstation. The medication is now simply left at the patient’s bedside contrary to written hospital policies and procedures. This method has now become the norm, a de facto practice.
The result is that each member of the healthcare team is now open to “interpreting the personal medication policy. Thus one nurse may still adhere by the written policy, while another nurse allows the medication at the bedside but insists on administrating it herself, while another nurse might even allow the patient or a family member to give the medication.
Should this scenario end in a negative outcome, not only is the hospital in a precarious position, but so are the nurses who have been following the de facto policy. This could result in a nurse being terminated for violating the written policy and procedure.
Managers might uphold a good written policy or procedure, but fail to take the added steps of reminding, informing or educating their team about the enforcement of said written policy or procedure. When a de facto policy has become standard practice, management must properly notify the healthcare team that from “this point forward” XYZ policy will be enforced.
It’s easy in the hurly burly pace of a nurse’s workday to take shortcuts that help make work easier and more efficient. But when you suspect that these shortcuts are becoming wrong turns, you must consult your chain of command. Your hospital’s policies and procedures are there for a good, as well as legal, reason. Review them and familiarize yourself with the ones that apply to your position as this safeguards both your patient’s well-being and your license to practice.
Geneviève M. Clavreul RN, Ph.D., is a healthcare management consultant who has experience as a DON and lecturer on hospital and nursing management. She can be reached at: (626) 844-7812; firstname.lastname@example.org