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.

Change of Shift: This week with a Highly Trained Monkey

Musings of a Highly Trained Monkey: Change of Shift: Volume Two, Number Three

Great collection of posts including mine with a nice touch of color.

A Vital Sign with concerning unintended consequences

Great post over at Aggravated Surgery Doc about the on the Downside of the 5th Vital Sign on how the PC infiltration of pain management policy caused poor patient outcomes and placed patients at higher risk. He makes valid points that political pressure has lead to more aggressive use of IV narcotic pain management instead of IM or other management thus putting patients at risk.

“In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management”

“Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain“

In my mind the crux of the issue is whether the pain scale is an accurate means of pain assessment (that’s a big NO!!!!!) and are people being harmed from more aggressive pain management (YEP!!!). A study published in the May 2007 Journal of the American College of Surgeons titled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign documents cases of preventable death directly related to pain management in surgical patients and how they have increased in the period after JCAHO’s rules. More concern here from Anaesthesiologist.

The study and experiences above relate mostly to surgical patients. My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Have a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these "Customers". Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.

I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by non medical Hospital Administrators. Kim wrote about that recently here and couldn't’t have said it better below. When a patient does not get their fix, I mean, appropriate pain management, that being IV or IM Demoral or Dilaudid with a mixer x 2 and Rx of Vicodin #30 as well as a six pack of Vicodin to go being they came in after the Pharmacies are closed, they tend to complain.

“The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given. The patient is so angry that they take it all the way up to the head administrator of the hospital. In person.The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately. This needs to be addressed. A meeting is called to address the patient’s issues. The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty. This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded. The patient is now given exactly what they ask for every time they come in by every doctor in the department”.

I may add that if the Nurse shows the least bit of a perceived judgmental attitude when carrying out the fix, I mean the order, they can expect a complaint and a negative evaluation, or worse from managers who are running scared over complaints. A judgmental attitude could be the Nurse inquiring about daily use of other medications, legal or illegal, that may potentate their ordered fix, I mean pain management, giving the big whopping dose of Dilaudid to slow (I put anything more than 1 mg IV on a pump over 20 min which has been called punitive), pressing the "Customer" to show they have a driver, or any type of attempted discharge education or suggestion related to their pain management practices.

If this practice has not hit your ER yet, consider yourself lucky for now.

Stroke Centers, Marketing or Medicine

You are out shopping on a hot summer day when you suddenly become a little dizzy. It comes and goes and you start having a minor headache and then your vision gets a little fuzzy. Your getting worried. In the back of your mind you remember that health fair you went to and the people at the booth sponsored by the local Hospital talking about signs and symptoms of stroke. Could this be a stroke? Possibly heat related or a migraine? You also remember what they told you. You must get to the hospital within 3 hours of the start of your symptoms to get the miracle clot busting drug if it is a Stroke. You tell your spouse and off you go to your local Hospital which has been certified as a Stroke Center by JCAHO.

Once in the Emergency Room your taken right back, people crowd around, off come your cloths, someone puts an IV in your arm and you’re rushed off for a Head CT. When you return you get an EKG, more blood tests and a lot of questions. A cheery young lady comes in and says she is the Stroke Coordinator. She talks with you and gives you some handouts and asks more questions. Then someone brings a big machine into the room and does an ultrasound of your heart and neck. Your symptoms seem to have subsided but you are admitted to the Hospital just as a precaution. The ER Doctor is still not sure if you had a TIA or some other problem. Since your better you don’t need the miracle clot buster drug. Good thing.

The response to a potential stroke patient is modeled much like the response to a trauma patient entering a Trauma Center. These patients go to the top of the priority list and command the resources of the facility. The goal initially is to identify rapidly if the potential stroke patient is a candidate for TPA. A wide net is cast where most every patient with any acute neurological presentation gets entered into the Stroke Protocol. Some communities have implemented EMS destination protocols so potential Stroke patients are routed to a Stroke Center. San Francisco did this and the response of the hospitals was the all became or have applied to be Stroke Centers.

So is all this good medicine or marketing to increase patient volume and charge for a lot of expensive procedures? The good medicine argument is subject to much debate just as TPA’s use for ischemic strokes is controversial. Grunt Doc in recent posts here and here sheds light on the controversy, mainly in response to a recent Wall Street Journal Article that promotes TPA. The main Emergency Medicine organizations have taken positions that TPA not be considered standard of care for Ischemic Stroke but be an option in certain cases. AAEM’s position statement can be viewed here The movement towards Stroke Centers seems to have steamrolled over the concerns of Emergency Physicians and is moving ahead at a brisk pace. A list of current Stroke Centers can be viewed here. The ED I work at is a Stroke Center. Some of the ED MD’s are very reluctant to give TPA but know its not a good career move for them or their ED group to not give it on a qualified candidate. So they do it. ED Physicians are in a no-win situation. They are likely to get sued for giving or not giving TPA if the outcome is not good.

The marketing aspect of Stroke Centers is closely tied to the marketing of TPA. The creation of, or at least the illusion of, TPA as the Standard of Care for Ischemic Stroke seems to be the strategy with an aggressive media campaign as well as involvement with the American Heart Association in setting standards. Genentech who makes TPA has promoted the establishment of Stroke Centers and has made it one of their marketing goals.

The “Stroke Center” paradigm provides a way to segment hospitals by their treatment patterns and shed light on how to overcome barriers to treating with TPA. Source:Genentech Stroke Assessment Market Research, 02/2003 – 07/2003

Genentech also offers educational grants to assist Stroke Centers in defraying the cost of educating their staff in stroke care. The American Heart Association, long criticized for recommending TPA’s use due to conflicts of interest of its Leadership, some with financial ties to Genentech and weak supporting data for TPA use in stroke, also is very involved in the Stroke Center concept and assists hospitals in getting Stroke programs started.

Genentech knows that promoting Stroke Centers will increase the use of TPA. One study showed an dramatic increase in TPA use at Stroke Centers versus non centers but no decrease in mortality or length of hospital stay associated with TPA. The real data out there does seem to support a modest decrease in long term disability when TPA is used according to strict criteria although some studies have actually shown an increase in mortality with TPA use. My suggestion would be to place this illustration on the TPA consent form which basically says, you may have less disability but your likelihood of a fatal hemorrhage is increased, and if your symptoms are not due to a stroke but some other neurological disorder you assume all the risk and none of the benefit, you make the call.

The Hospital I work holds Stroke Fairs catering to senior citizens. They have speakers go to community events and organizations. More than once I have seen or read material distributed or articles in the local newspaper or directly heard reference to getting to the hospital early to get the “miracle clot busting drug”. Is this information helpful? accurate? The education on lifestyle changes and symptom recognition is very helpful but I have big concerns about the promotion of TPA and minimization of risks. Again, perhaps the above chart which was produced by AAEM should accompany the handouts.

So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.

Should the University of California Invest in Nurses or Lawyers…. Hmmmm!! Updated Aug 07

Dan Walters, a columnist with the Sacramento Bee has a reputation for calling government on the carpet for its wasteful spending and misdirected priorities. California corners the market on government waste and misdirected priorities and the University of California tops the list within California government. Their mis-management of public money is infamous. Just a few examples, here, here, and here.

Walters comments here on the recent decision of the University of California at Irvine to open a new law school despite a recommendation by the California Post secondary Education Commission’s not to citing an ample supply of lawyers in California, approximately 200,000. Roughly the same number as practicing Registered Nurses in the State. The full report of the Commission can be viewed here. Walters suggests Nursing education would be a better use of public resources.

It's another illustration of the fundamental dysfunctionality of California's government, its chronic inability to relate to real-world issues and prioritize its limited resources. UC's regents and administrators want to establish a new law school at Irvine because it would, in their view, enhance the school's prestige and, by extension, their own, not to meet any true educational or societal need…….

The Legislature's budget analyst, Elizabeth Hill, issued a report on the state's looming shortage of nurses in May, noting that the University of California, in a study by its San Francisco medical school, forecast a demand for registered nurses in 2014 that's 40,000 higher than the current forecast of supply, given retirement and other factors.

Hill recommended several steps, including supplemental funding to expand nursing education programs and removal of artificial barriers to expansion. The issuance of her report was virtually simultaneous with another event -- a vote by UC regents to authorize UC Irvine to hire a founding dean for its proposed law school at an annual salary of $233,200 to $364,300. It was the regents' figurative thumb of the nose to CPEC and its position

Some would argue the University is not tasked with “vocational education” which is normally handled by the States Community College System. Without even addressing the Vocation vs Profession argument the Nursing shortage in California is closely related to the number of Nursing programs available to students which is closely related to the number of qualified advanced degree Nurses to teach those students. Would it not be a better use of taxpayer money for the UC system to try to address the real issues facing the public rather than producing a surplus of Attorneys and building their Ivory Towers.

I cant wait for the sequel. The inevitable audit of how UC spent its millions of Stem Cell monies.

UPDATE August 07: UC Davis just announced the start-up of a new Nursing Program. Could I be wrong about UC liking lawyers more than Nurses. Nahhhh. They got a 100 million dontation to get it started. Regardless of the motives I'm glad to see more training in the pipeline.

ER Doc reacts to Nursing Ratio’s and Unionization

Posted at Backstage Pass ER Doctor blogs on the down side, as she sees it, of California’s Nursing Ratios effect on Emergency Departments and patient care. A lot of this is venting but worthy of ED Nurses review and consideration. I have seen this opinion expressed widely among my EM Physician Colleagues. Organized initiatives such as diminishing the RN’s role in Triage and other corner cutting measures are a reflection of it. So the question, Is there a backlash forming against Nursing's success in healthcare and patient advocacy and job protections? I'm feeling it!!

5.12.2007
Nursing ratios
4:1 nursing ratio...sounds like a good idea on the surface.But I tell you what - if you're in the ED waiting room, dying of a brain bleed; or if you're sitting in triage with an open fracture in excruciating pain, you'd appreciate one tenth of a nurse if it meant basic treatment......

...."Basically, nursing ratios are not good for the patients when there are already not enough nurses.......unless, of course, you're one of the first 4 to arrive".
Posted by ER doctor at 11:05 AM

I have been on both sides of this issue, formally against ratios while in ED Nursing Management, and now very much for them working at the Staff Level. I am convinced I am on the right side now, more evidence here. I made comments on ED Doctor's post regarding my support of ratios and got an interesting comment that followed. Worth a read.

ER Doctor in this post and another on Nursing Unionization express anger that Physicians and their organizations did not take an earlier stance on this issue and others and are not organized like the Nurses which advocates the balance of power to Nursing. Hey, thanks for the complement or at least acknowledgement that were kicking your butts. Were used it. We have to every day just to keep things flowing and our patients safe. Hopefully, after you vent you will realize that our advocacy is to your benefit and patients benefit. Yes, some Nurses do take advantage of the ratio's but the overall effect is good for patients. I do sense your anger and see some of your points. Others are just plain wrong like a RN can be cooked up from scratch in 2 years.

In another post ED Doctor writes

5.23.2007
Letter to my peers on unionizing
(I will kindly *not* include myself in this)Doctors are stupid, because they have allowed this to happen.Still living in an era of the rich, private practice mentality...not accepting the fact that most physicians today are employees in one way or another. And instead of turning up their noses to unionizing, perhaps they should realize that they are now more like the average worker. They've allowed the nursing union to be the be the sole legislative voice on healthcare policy, to their detriment, and to the detriment of their patients.As the nursing union shouts "patient advocacy," they are trying to implement healthcare policy that actually hurts the poorest, sickest, neediest members of our society (I'll elaborate as needed). The whole while, the AMA/CMA (made up of mostly people who are completely out of touch with young physicians) asks for money, but does nothing to help their cause. Time after time, taking "no position" on matters that make a huge difference with regard to modern physician's issues. Case in point - the Governor's proposed tax on doctors and hospitals. The doctor's are getting fucked, and there is no unified voice advocating on their behalf. Therefore, patients are getting fucked, and healthcare is a complete mess. And where are the doctors? Where is their voice. What solutions are *they* offering?Doctors need to change their thinking, hold the medical societies accountable, (or refuse to join), participate in the legislative process, and drop the arrogance against unionizing. Or we can all prepare for complete chaos as healthcare continues to fall apart, without a legitimate beacon of leadership. As the doctors bury their heads in their arrogant asses, allow everyone else to take control, and then wonder why they are (directly) paying for a shitty healthcare system, run by nurses/chiropractors/optometrists/herbalists/and the 'people at the healthfood store.'Get a clue.

Posted by ER doctor at 1:50 PM 4 comments
Labels: Issues

Nurses need to be aware that a Physician backlash is taking place and be prepared to defend our practice and ability to perform patient advocacy.

Top Ten ways to raise your Emergency Department Satisfaction scores

So you’re a Hospital CEO, Emergency Physician Director, or ED Manager. Your latest patient satisfaction scores are lower than your competitor Hospital across town and your in a panic. The results are in the newspaper. Your job is on the line. Try this Nurse’s tried and true top 10 list of how to raise your scores in a hurry. Get your staff on board, here is how.

10. Prescribe Tylenol and other OTC meds: Patients love it because it will mean that their health coverage might cover the cost (at least publicly funded plans will). What’s a little ink on a prescription pad if it moves you up a notch on the survey.
9. Make the Nurses Apologize: Remember, the customer is always right. No matter how dysfunctional and disruptive their behavior apologize if anything upsets them. Smoking in the bathroom, cussing at the Nurses, no problem. If the Nurses refuse have the supervisor apologize and offer the patient a free drink voucher in the cafateria for not meeting their expectations. You can deal with this obvious case of insubordination later.
8. “MR CEO Take down these walls”: Eliminate secure entrances and relax visiting policies. They are only there because those damm Nurses are control freaks. Let the family in and make ER care a group event. Now isn’t everyone happy. More people to practice your scripts on (see #1). Besides, the odds are in your favor you wont have a security event. At least during your tenure as CEO, Director, or Manager. Here is one facility that was not so lucky.
7. Don’t spend to much energy on those excluded from the survey: Quietly leak out who is excluded from the survey (most institutional and mental health patients, and transfered patients in case you are curious) so staff can direct their energies appropriately. Hey, even a demanding CEO knows that you can only kiss so much butt per shift. The key is kissing the right butts.
6. Valet parking: If cost is an issue, lay off your ER Techs, or if you feel bad about that just change their job description, have them put on a suit and park those cars.
5. Prescribe antibiotics for every cough and ear ache: Again, the customer is always right and we dont treat patients, we treat customers. They didn’t drive all this way to get told a viral illness will not benifit from antibiodics and to take Motrin, drink lots of fluids, avoid second hand smoke, and rest. No, give them an antibiotic. Who cares about the treatment guidelines, this one is not measured. They will get better regardless in a couple of days and no doubt will attribute it to the antibiotic. And give them the good stuff, Cipro, makes them feel special and gives you bonus points come survey time. Also good for many bioterrorism events.
4. Hire Travel Nurses: The best thing about Travel Nurses is there easy to get rid of. Yes they are expensive but so is orientation, training, benefits, continuing education, step raises, and all the other stuff that your staff nurses have come to expect. Travel Nurses are not interested in the politics, problems, and shortcomings of the institution, or patient advocacy. They will come to work and not complain, generally be nice, and do as they are told. If they dont, send them packing.
3. Minimize threatening patient education: Crutch walking, wound care instructions, fever control, all great stuff but don’t let those Nurses get to proactive in educating patients. You can loose survey points if some Nurse talks to much about the dangers of smoking, obesity, shaking your child, or any other threatening subject. If the Nurses don’t comply limit their ability to give instructions by eliminating those handouts or use a electronic record that gives instruction control to the Doctor (like Tsystem). After all, Doctor does know best.
2. Provider is Triage: Replace your Triage Nurse with a Midlevel Provider. Your Midlevel can treat and street in a 1 minute Triage exam most of your common complaints as long as they do not engage in any meaningful conversation and follow items 10, 7, 5, and 3 as above. The Nurse, should you choose to keep one in Triage, can stand behind the Provider and quietly scribe the notes. You can call it "Team Triage" and tell them how importnat they are to the "Team". You’ll need a good generic checklist type H&P intake form (I recommend Tsystem or equivalent). The more complex patients will be assigned to the ER for the MD to see. But guess what, you can reduce your ER’s Door To Provider time to nearly zero on all patients by having your PA scribble down some preliminary orders before handing the patient over. Who cares if they ever get done. This is chart buffing at its finest.
1. Scripting to the Test: Teach your staff to memorize the test questions that patients get on their survey so you can have them script their conversation and prompt the patient to remember specifics when filling out their survey. “I am closing the curtain to protect your privacy Mr Jones” will score high on the question “The Nurse paid attention to my privacy needs? “Thank you for choosing Acme Medical Center for your care provider”. This one will get you a more likely to recommend. Not only does scripting guide the patient in completing their survey, it eliminates unnecessary Nurse conversation.

The sad part of this list is the items cited are becoming common practice at many Healthcare organizations.