Remote CPOE error and the relationship to Critical Thinking Nurses

In recent past post on several blogs I, along with numerous others, engaged in some back and forth banter about the appropriateness of Nurses questioning Dr’s treatment orders. I remember one of the quotes of someone, I presume an MD, who expressed strong feelings about having his judgment questioned by a Nurse, “Because I’m the Doctor, that’s why” and other comments to the effect of What Medical School did you go to blah blah blah. A couple examples of this attitude mostly in the comments on posts here, and here. I have had similar discussions in my various workplaces over the years with a few MD’s who expressed similar opinions. Fortunately they are in the minority. Most Physicians value Nursing input and recognize the benefits to themselves as well as patients.

I ran across an interesting article in the newsletter from the Institute for Safe Medication Practices that puts this argument in perspective for me.

From the May 31, 2007 issueProblem: ISMP received a report from a hospital where a medical resident had prescribed a NORCURON (vecuronium) infusion for the wrong patient via a computerized prescriber order entry (CPOE) system in a remote location. She meant to order the infusion for a ventilated patient in ICU but accidentally prescribed the drug for a patient on a medical unit.

ERMurse’s opinion on how this could of happened. Most EMR systems have features called Patient Lists which are very valuable for staff seeing patients in multiple locations especially in large facilities. For example, all patients assigned to a particular admitting service populate the Service List and individual practitioners can create their own lists adding patients manually. They work from these list extensively. In the electronic world a lot of work can be done remotely from the patients location. I suspect the Resident simply picked the wrong person from the list and the system did not have enough strategically placed visual cues in the list or on each screen of the patient record for the Resident to recognize the error. The placement on the list of appropriate patient identifiers and location can help in orientation to what patient you have accessed. Once in the record, did each screen have a prominent view across the top that displayed the patients name and location. Some EMR systems do, others once you pick a patient and begin wading through the various order and documentation screens you loose orientation of which patients record your on. Busy people get interrupted frequently and can resume work thinking they are on one patient and are actually on another. Simple design decisions and consistency of design in an EMR can keep the clinicians oriented to the correct patient or not.

An inexperienced resident pharmacist processed the order and prepared the infusion, failing to recognize that a neuromuscular blocking agent should never be sent to a medical unit where patients are not intubated and on ventilators. The resident pharmacist affixed two labels to the bag: one noting that the infusion was a high-alert medication, and the other stating that the drug was a “paralyzing agent.” The pharmacy technician who delivered the infusion did not think to question why the medication had been pre-scribed for a patient on the medical unit. An independent double-check was required for this medication before administration, so two nurses verified the drug, pump settings, and patient.

You think those 2 Nurses left something out? They did the 5 rights of med checking, well sort of. You can verify the order, route, patient, dose, and time and make this error if you do not possess the critical thinking skills to understand (or research) what your giving and why your giving it. My initial gut reaction is that all the people involved in the chain are incompetent. That may be the case but knowing the culture of the institution or floor is an important consideration in determining how this happened. Do the Nurses view themselves as independent licensed professionals with a duty to know their patients conditions and reasons for treatments and feel free to question Physicians on care issues or do they view themselves simply as being there to follow orders without understanding or questioning. A surprising number of Nurses practice this way. I do believe there is a cultural element in Nurses who do not critically think. In some cases it is the culture of the institution that discourages critical thinking, in others I believe it is a reflection of the culture of the Nurses and where they were trained which in my experience is more common among some foreign trained Nurses.

The infusion was started, after which the patient began walking to the bathroom. He fell to the floor once paralysis began to set in, but fortunately, he was able to call out for help. The resident physician was called, along with the rapid response team. When the team arrived and asked what happened, one of the nurses questioned whether the “new drug” she had just hung could be responsible. Realizing the problem, the physician immediately stopped the infusion.

Talk about a Shit your pants moment when that Doc looked up and saw Vec hanging on a Med Surg patient. I would have loved to have been a fly on the wall to see the expressions on the faces in that room.

The prescribing error escaped the attention of at least five staff members–the physician, pharmacist, pharmacy technician, and two nurses. The error was also able to get through the system despite safeguards such as warning labels and double-checks. It is also likely that the nurses working on the medical unit, where the drug had never been used, had little knowledge of Norcuron, its indication, its paralytic effect, and the need for mechanical ventilation, despite the warning label…..

Most likely, the problem was not that the nurses did not carry out an independent double-check according to a typical process used in many hospitals–independently comparing the “five rights” against the physician’s orders or a verified MAR.In fact, the nurses followed the physician’s orders perfectly. What is missing in the double-checking process is a cognitive review of the appropriateness of the drug, dose, and route of administration.

That’s why you look up meds your not familiar with and question any order that does not fit the picture. Getting back to the “Because I’m the Doctor” attitude I have only one thing to say, Be careful for what you ask for in how you would like Nurses follow your orders and not question your judgment. The result might not be in your best interest or the patients.