The following is a post taken from the Blog called Code Blog:Tales of a Nurse
Grand Rounds Volume 6, Number 6
October 27, 2009 Welcome to Grand Rounds! This is volume 6, number 6…. and the 6th time I am hosting… during the week of Halloween. Does anyone else find that creepy coincidentally satanic fascinating?!
For this edition, I thought we could go out Trick or Treating on Medblogger Lane. I’m sure we will find some colorful stories along the way…
The first house we come to seems amiable enough. The porch light is on and when the door is answered, some good old fashioned chocolate is put into my Trick or Treat bag! Even though she is diabetic, apparently Amy at Diabetes Mine prefers to give out the real stuff instead of the sugar-free kind. The reason may surprise you.
The next house also has the porch light on, but no one answers the door when I ring the bell. Finally I notice a note that says I should just take some candy from the bowl. Not Nurse Ratched is horribly sick with H1N1 and doesn’t want to spread any germs. Read her first-hand account of what it’s like to be knocked out by this flu.
Dr. Bates from Suture for a Living is at the next house. She has some great candy but it was kind of a pain to get. She said that the candy was password-protected and that I had to prove that I had a professional responsibility to eat the candy, and would not eat it out of mere curiosity. Take a gander at what happens when HIPAA is peering over your shoulder when you go looking around where you shouldn’t.
The next house was just crazy. When I arrived, they would only open the gate to let me in if I was wearing a face mask. Laika from MedLibLog wasn’t taking any chances after watching this very descriptive video that shows how the flu virus is transmitted and starts taking over the cells in your body. When I finally got past the gate, Dr. Val from Better Health informed me that she would love to give me some candy, but unfortunately the Big Candy Store down the block ordered it all up and now there wasn’t any left. So I wouldn’t feel as though I wasted a trip (and a mask!), Dr. Anonymous sat me down and told me all about the candy H1N1 flu, including busting some myths about the vaccine and informing me of when it might be available. On my way to the next place, I passed someone dressed up as a shark. That reminded me of Dr. Auerbach’s post at Healthline.com about shark attacks – why they attack and steps we can take to avoid being attacked. I was especially amused at reading this: “…it is important to note that any shark, including the seemingly docile nurse shark, will bite a human if sufficiently provoked.” I’m sure there are a few doctors out there who learned that the hard way.
I finally arrived at the Medblogger Lane Haunted House. It was with much trepidation that I walked through the front door…
…and had to stifle a scream as I entered the room! A mad scientist was performing various experiments on poor unsuspecting subjects. You would think that a little playful squirt of lime would result in no harm, but Dr. Charles explains how it could end up badly. The adjacent hallway was dark and a little spongy. It seemed strangely reminiscent of a certain screening exam. The Clinical Cases & Images Blog gives us the quick and easy Cliff Notes version of colorectal screening guidelines. Allergy Notes describes the scary effects of sulfite hypersensitivity. In another room Sharp Brains had specimens in jars and was performing tests to find out if caffeine had a sustained lifetime benefit or harm.
The last room had people who have had very scary things happen to them. Trauma Junkie described a typical day in the life for a patient with Cystic Fibrosis and shares his newfound wisdom about how sometimes the patient teaches the practitioner. Chris at Life in the Fast Lane relates a story with a very important lesson: sometimes we need to dig a little deeper and ask a few more questions before the medical mystery can be solved. And Robin at Survive the Journey describes what it’s like to parent a child who has Cushing’s Disease, from diagnosis and management to terrifying flare-ups and hospitalizations.
After all that, I was ready to get back to some more trick or treating! The next house I came upon was giving out gift certificates to iTunes! I thought that was perfect because I could use it to check out some of the Anatomy software apps on Dr. Penna’s list. As I was leaving, I overheard a conversation about a laptop being stolen from Blue Cross Blue Shield and the potential damage that could result. Dr. Joseph Kim from Non-Clinical Jobs lets us know what to do in case we find ourselves in this predicament.
I finally arrived at a huge scary house… you know, the kind that is decked to the nines in Halloween decorations… the one that makes your heart go just a little faster as you’re walking up to the porch. I rang the bell, said “Trick or Treat!” and waited. And waited some more. Surely a house as big and fancy as this would have great candy, right?! Finally a piece of paper was slipped under the door. It asked if I had any conditions that would be exacerbated by procuring and ingesting sweet edibles. It further stipulated that I needed to meet a minimum threshold of candy before they would provide me with any more! What was this? Some kind of confectionery deductible? I concluded that I had unwittingly arrived at the House of Insurance.
Instead of filling out the forms that had piled up outside, I decided to sneak in the back door to see if I could find out anything interesting, and boy did I ever…
Insure Blog was trying to figure out how Washington would handle 14 million new patients finding themselves on Medicaid if the Baucus health care bill is enacted. Louise at the Colorado Health Insurance Insider was pondering the composition of hospital boards of directors – are they comprised of objective participants, or is there some significant conflict of interest going on? And in the corner was a group led by Leslie at Getting Closer to Myself discussing the merits of marrying for love… or insurance coverage.
By this time it was getting late and I decided to head home. I spotted a big bonfire along the way and decided to stop by to see what was going on. Several people were gathered around the fire sharing experiences and information. Jolie Bookspan at the Fitness Fixer described several ways to treat knee pain that do not involve scalpels. Jenni at ChronicBabe informed us about fibromyalgia and contributed a list of resources that provided education on how to live and even thrive with the disease. Jeffrey at Nuts for Healthcare explained that fibromyalgia remains controversial in the medical community; however, while drug companies have been accused of fear-mongering to a desperate population for a handsome profit, recent neurological research has begun to unravel the biological manifestations of the disease in the hope to pinpoint a cause.
Novel Patient proudly described how she painstakingly stood up against her chronic illness and disappointing new diagnosis. Rachel at talesofmy30’s divulged her secret for learning to love her body after enduring disordered eating patterns and a type 2 diabetes diagnosis. Stacey at ACP Internist spoke about a possible reason as to why medical students are not going into primary care. David Harlow at HealthBlawg gave a detailed account of his experience at the Connected Health Symposium 2009 conference held last week in Boston. To finish the evening, Barbara at In Sickness and In Health shared with us a story she told her father while he was ill in the hospital.
That’s all for this edition of Grand Rounds. Next week, Grand Rounds will be held at nonclinicaljobs.com.
Have a safe and happy Halloween everyone!
Wednesday, November 4, 2009
Thursday, September 10, 2009
Sunnybrook performs minimally invasive, beating-heart bypass surgery
Dr. Moussa came to PAC today to present an in service on his Minimally Invasive, Beating Heart Bypass today. He has so far done 8 procedures here at Sunnybrook, and is one of 2 surgeons in Ontario performing this procedure!
Thursday, August 27, 2009
Updates
I came across this site this morning that I thought might be of interest: Safety Share
Many new initiatives are going on around the hospital, many geared towards patient safety. Policies currently being worked on: Conscious Sedation, Transfer of Accountability, Procedures Performed on Correct Side of Patient(being updated!) As well, there is a Surgical Safety Checklist being developed-an initiative recommended by the WHO. For the Regional Block area, there is a mini checklist being developed.
SPANC has two new co-chairs: Sandi Weir and Lan Zhou. They are looking for committed PeriAnesthesia nurses to meet once a month. They need suggestions on unit initiatives.
There is an Environmental Sustainability Committee and Laurie R has already placed a Recycling bin in the PACU with instructions regarding the types of paper and plastics that can go in the one bin. Bins will be coming to PAC, SDS, SSSU soon.
Many new initiatives are going on around the hospital, many geared towards patient safety. Policies currently being worked on: Conscious Sedation, Transfer of Accountability, Procedures Performed on Correct Side of Patient(being updated!) As well, there is a Surgical Safety Checklist being developed-an initiative recommended by the WHO. For the Regional Block area, there is a mini checklist being developed.
SPANC has two new co-chairs: Sandi Weir and Lan Zhou. They are looking for committed PeriAnesthesia nurses to meet once a month. They need suggestions on unit initiatives.
There is an Environmental Sustainability Committee and Laurie R has already placed a Recycling bin in the PACU with instructions regarding the types of paper and plastics that can go in the one bin. Bins will be coming to PAC, SDS, SSSU soon.
Tuesday, August 11, 2009
On Colonoscopies...
Thought I'd add a little humour...
ABOUT THE WRITER Dave Barry is a Pulitzer Prize-winning humor columnist for the Miami Herald.
Colonoscopy Journal: I called my friend Andy Sable, a gastroenterologist, to make an appointment for a colonoscopy.
A few days later, in his office, Andy showed me a color diagram of the colon, a lengthy organ that appears to go all over the place, at one point passing briefly through Minneapolis.
Then Andy explained the colonoscopy procedure to me in a thorough, reassuring and patient manner.
I nodded thoughtfully, but I didn't really hear anything he said, because my brain was shrieking, 'HE'S GOING TO STICK A TUBE 17,000 FEET UP YOUR BEHIND!'
I left Andy's office with some written instructions, and a prescription for a product called 'MoviPrep,' which comes in a box large enough to hold a microwave oven. I will discuss MoviPrep in detail later; for now suffice it to say that we must never allow it to fall into the hands of America's enemies.
I spent the next several days productively sitting around being nervous.
Then, on the day before my colonoscopy, I began my preparation. In accordance with my instructions, I didn't eat any solid food that day; all I had was chicken broth, which is basically water, only with less flavor.
Then, in the evening, I took the MoviPrep. You mix two packets of powder together in a one-liter plastic jug, then you fill it with lukewarm water. (For those unfamiliar with the metric system, a liter is about 32 gallons). Then you have to drink the whole jug. This takes about an hour, because MoviPrep tastes - and here I am being kind - like a mixture of goat spit and urinal cleanser, with just a hint of lemon.
The instructions for MoviPrep, clearly written by somebody with a great sense of humor, state that after you drink it, 'a loose, watery bowel movement may result.'
This is kind of like saying that after you jump off your roof, you may experience contact with the ground.
MoviPrep is a nuclear laxative. I don't want to be too graphic, here, but, have you ever seen a space-shuttle launch? This is pretty much the MoviPrep experience, with you as the shuttle. There are times when you wish the commode had a seat belt. You spend several hours pretty much confined to the bathroom, spurting violently. You eliminate everything. And then, when you figure you must be totally empty, you have to drink another liter of MoviPrep, at which point, as far as I can tell, your bowels travel into the future and start eliminating food that you have not even eaten yet.
After an action-packed evening, I finally got to sleep.
The next morning my wife drove me to the clinic. I was very nervous. Not only was I worried about the procedure, but I had been experiencing occasional return bouts of MoviPrep spurtage. I was thinking, 'What if I spurt on Andy?' How do you apologize to a friend for something like that? Flowers would not be enough.
At the clinic I had to sign many forms acknowledging that I understood and totally agreed with whatever the heck the forms said. Then they led me to a room full of other colonoscopy people, where I went inside a little curtained space and took off my clothes and put on one of those hospital garments designed by sadist perverts, the kind that, when you put it on, makes you feel even more naked than when you are actually naked..
Then a nurse named Eddie put a little needle in a vein in my left hand. Ordinarily I would have fainted, but Eddie was very good, and I was already lying down. Eddie also told me that some people put vodka in their MoviPrep. At first I was ticked off that I hadn't thought of this, but then I pondered what would happen if you got yourself too tipsy to make it to the bathroom, so you were staggering around in full Fire Hose Mode. You would have no choice but to burn your house.
When everything was ready, Eddie wheeled me into the procedure room, where Andy was waiting with a nurse and an anesthesiologist. I did not see the 17,000-foot tube, but I knew Andy had it hidden around there somewhere. I was seriously nervous at this point.
Andy had me roll over on my left side, and the anesthesiologist began hooking something up to the needle in my hand.
There was music playing in the room, and I realized that the song was 'Dancing Queen' by ABBA. I remarked to Andy that, of all the songs that could be playing during this particular procedure, 'Dancing Queen' had to be the least appropriate.
'You want me to turn it up?' said Andy, from somewhere behind me.
'Ha ha,' I said. And then it was time, the moment I had been dreading for more than a decade. If you are squeamish, prepare yourself, because I am going to tell you, in explicit detail, exactly what it was like.
I have no idea. Really. I slept through it. One moment, ABBA was yelling 'Dancing Queen, feel the beat of the tambourine,' and the next moment, I was back in the other room, waking up in a very mellow mood.
Andy was looking down at me and asking me how I felt. I felt excellent. I felt even more excellent when Andy told me that It was all over, and that my colon had passed with flying colors. I have never been prouder of an internal organ.
On the subject of Colonoscopies... Colonoscopies are no joke, but these comments during the exam were quite humorous..... A physician claimed that the following are actual comments made by his patients (predominately male) while he was performing their colonoscopies:
1. 'Take it easy, Doc. You're boldly going where no man has gone before!'
2. 'Find Amelia Earhart yet?'
3. 'Can you hear me NOW?'
4. 'Are we there yet? Are we there yet? Are we there yet?'
5. 'You know, in Arkansas , we're now legally married.'
6. 'Any sign of the trapped miners, Chief?'
7. 'You put your left hand in, you take your left hand out...'
8. 'Hey! Now I know how a Muppet feels!'
9. 'If your hand doesn't fit, you must quit!'
10. 'Hey Doc, let me know if you find my dignity.'
And the best one of all: 11. 'Could you write a note for my wife saying that my head is not up there?'
ABOUT THE WRITER Dave Barry is a Pulitzer Prize-winning humor columnist for the Miami Herald.
Colonoscopy Journal: I called my friend Andy Sable, a gastroenterologist, to make an appointment for a colonoscopy.
A few days later, in his office, Andy showed me a color diagram of the colon, a lengthy organ that appears to go all over the place, at one point passing briefly through Minneapolis.
Then Andy explained the colonoscopy procedure to me in a thorough, reassuring and patient manner.
I nodded thoughtfully, but I didn't really hear anything he said, because my brain was shrieking, 'HE'S GOING TO STICK A TUBE 17,000 FEET UP YOUR BEHIND!'
I left Andy's office with some written instructions, and a prescription for a product called 'MoviPrep,' which comes in a box large enough to hold a microwave oven. I will discuss MoviPrep in detail later; for now suffice it to say that we must never allow it to fall into the hands of America's enemies.
I spent the next several days productively sitting around being nervous.
Then, on the day before my colonoscopy, I began my preparation. In accordance with my instructions, I didn't eat any solid food that day; all I had was chicken broth, which is basically water, only with less flavor.
Then, in the evening, I took the MoviPrep. You mix two packets of powder together in a one-liter plastic jug, then you fill it with lukewarm water. (For those unfamiliar with the metric system, a liter is about 32 gallons). Then you have to drink the whole jug. This takes about an hour, because MoviPrep tastes - and here I am being kind - like a mixture of goat spit and urinal cleanser, with just a hint of lemon.
The instructions for MoviPrep, clearly written by somebody with a great sense of humor, state that after you drink it, 'a loose, watery bowel movement may result.'
This is kind of like saying that after you jump off your roof, you may experience contact with the ground.
MoviPrep is a nuclear laxative. I don't want to be too graphic, here, but, have you ever seen a space-shuttle launch? This is pretty much the MoviPrep experience, with you as the shuttle. There are times when you wish the commode had a seat belt. You spend several hours pretty much confined to the bathroom, spurting violently. You eliminate everything. And then, when you figure you must be totally empty, you have to drink another liter of MoviPrep, at which point, as far as I can tell, your bowels travel into the future and start eliminating food that you have not even eaten yet.
After an action-packed evening, I finally got to sleep.
The next morning my wife drove me to the clinic. I was very nervous. Not only was I worried about the procedure, but I had been experiencing occasional return bouts of MoviPrep spurtage. I was thinking, 'What if I spurt on Andy?' How do you apologize to a friend for something like that? Flowers would not be enough.
At the clinic I had to sign many forms acknowledging that I understood and totally agreed with whatever the heck the forms said. Then they led me to a room full of other colonoscopy people, where I went inside a little curtained space and took off my clothes and put on one of those hospital garments designed by sadist perverts, the kind that, when you put it on, makes you feel even more naked than when you are actually naked..
Then a nurse named Eddie put a little needle in a vein in my left hand. Ordinarily I would have fainted, but Eddie was very good, and I was already lying down. Eddie also told me that some people put vodka in their MoviPrep. At first I was ticked off that I hadn't thought of this, but then I pondered what would happen if you got yourself too tipsy to make it to the bathroom, so you were staggering around in full Fire Hose Mode. You would have no choice but to burn your house.
When everything was ready, Eddie wheeled me into the procedure room, where Andy was waiting with a nurse and an anesthesiologist. I did not see the 17,000-foot tube, but I knew Andy had it hidden around there somewhere. I was seriously nervous at this point.
Andy had me roll over on my left side, and the anesthesiologist began hooking something up to the needle in my hand.
There was music playing in the room, and I realized that the song was 'Dancing Queen' by ABBA. I remarked to Andy that, of all the songs that could be playing during this particular procedure, 'Dancing Queen' had to be the least appropriate.
'You want me to turn it up?' said Andy, from somewhere behind me.
'Ha ha,' I said. And then it was time, the moment I had been dreading for more than a decade. If you are squeamish, prepare yourself, because I am going to tell you, in explicit detail, exactly what it was like.
I have no idea. Really. I slept through it. One moment, ABBA was yelling 'Dancing Queen, feel the beat of the tambourine,' and the next moment, I was back in the other room, waking up in a very mellow mood.
Andy was looking down at me and asking me how I felt. I felt excellent. I felt even more excellent when Andy told me that It was all over, and that my colon had passed with flying colors. I have never been prouder of an internal organ.
On the subject of Colonoscopies... Colonoscopies are no joke, but these comments during the exam were quite humorous..... A physician claimed that the following are actual comments made by his patients (predominately male) while he was performing their colonoscopies:
1. 'Take it easy, Doc. You're boldly going where no man has gone before!'
2. 'Find Amelia Earhart yet?'
3. 'Can you hear me NOW?'
4. 'Are we there yet? Are we there yet? Are we there yet?'
5. 'You know, in Arkansas , we're now legally married.'
6. 'Any sign of the trapped miners, Chief?'
7. 'You put your left hand in, you take your left hand out...'
8. 'Hey! Now I know how a Muppet feels!'
9. 'If your hand doesn't fit, you must quit!'
10. 'Hey Doc, let me know if you find my dignity.'
And the best one of all: 11. 'Could you write a note for my wife saying that my head is not up there?'
Wednesday, July 22, 2009
Automated Dispensing Cabinets
We are currently working with pharmacy to get the McKessin cabinets up and running. I found this article on Medscape and thought I would share it on the blog. Happy reading!
From Topics in Advanced Practice Nursing eJournal > Commentary
Automated Dispensing Cabinets: Getting It Right in the Age of Automation
Barbara L. Olson, MS, RN-BC, FISMP
Just as the brand name Kleenex® is commonly used for facial tissues, automated dispensing cabinets (ADCs) are often recognized by manufacturer or product names such as AcuDose®, Omnicell®, and Pyxis®. Currently, 83% of US hospitals report that they use ADCs, indicating widespread acceptance of touchscreen-activated drug storage vaults.[1] Generally welcome additions to busy clinical settings, ADCs provide ready availability of medications (a key component of acute care) while streamlining the process of drug charging.
But ADCs are more than automated teller machines for drugs. These unit-based medication repositories incorporate sophisticated software and electronic interfaces to synthesize high-risk steps in the medication use process. Today's cabinets reflect design advances as well as an appreciation for how specific technologies, such as barcode scanning and clinical decision support, can improve medication safety. Over the years, ADCs have been adapted to facilitate compliance with emerging regulatory requirements such as pharmacy review of medication orders and safe practice recommendations.
Promoting Medication Safety
The "5 rights" of medication administration, a set of objectives well-known to nurses and other frontline clinicians, are often used to describe medication safety goals. When used to their greatest potential, ADCs can increase the reliability of the "5 rights": the right drug, the right dose, the right patient, the right route, and the right time. The mirror image of each medication right is a wrong -- wrong drug, wrong dose, wrong patient, wrong route, and wrong time -- representing a risk point that a strong system design can help to avert.
However, sophisticated, accessible drug storage systems alone do not guarantee safety. Selection, design, implementation, and monitoring of ADCs are also important to mitigate the risk associated with medication use.
In 2008, the Institute for Safe Medication Practices published Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets to help organizations and individuals understand and adopt practices that maximize the safety of ADCs.[2] Twelve distinct core processes that promote safest practices and secure handling of drugs are addressed in this document. While these guidelines do not represent standards of care, they do provide organizations and frontline users with measures for each stage of ADC implementation, from deciding how the technology will be used to staff education and long-term monitoring.
The ISMP guidance document, coupled with other relevant literature and reports of error and near-miss events associated with ADC use, inform the recommendations provided below. These quick-read recommendations are by no means inclusive, but may serve to bridge understanding between executive decision makers, medication safety experts, and frontline clinicians during high-stakes decision processes that involve resource allocation, work-flow, and patient safety. Teams charged with ADC implementation or re-evaluation as well as those interested in defining pharmacy-specific processes to enhance ADC safety are advised to consult ISMP's complete document.[2]
Wrong Drug/Wrong Dose Errors
Wrong drug and wrong dose errors are the most common errors associated with ADC use. Look-alike drug names and drug packages are variables that can lead to wrong-drug/wrong-container selection errors. Morphine and hydromorphone (Dilaudid®), for example, are 2 different opioid analgesics that top the list of the most frequently confused drugs.[3] Alprazolam and lorazepam are another pair of look-alike, sound-alike drugs that are frequently confused.
Environmental factors (such as distraction and lighting) influence how well humans perform tasks involving product selection. Patient information at the point of dispensing, such as allergies and potential contraindications, allow a final cognitive check (matching prescribed drug, dispensed drug, and indication for use) to occur.
Consider this comment, made by a seasoned nurse who responded to a post entitled "Meds & Mindfulness" on Medscape's On Your Meds blog in April 2009:
I have been an RN since 1974 and have worked in many settings. I am currently on a geriatric psychiatric unit and I just wanted to share that my morning med pass is just about the most unnerving thing I have ever done. The area where 2 of us prepare our meds is a small hallway through which people must pass to reach our unit tube system. Folks squeeze by often as we work. On the other end of our small area is our Pixis (sic) machine, which the pharmacy tech comes to stock during the time we are setting up our meds...... Interruption is the name of the game.
This nurse's observations highlight several of the well-known risk points in the medication use process that contribute to wrong drug/wrong dose errors.
Recommendations to Prevent Wrong Drug/Wrong Dose Errors With Automated Dispensing Cabinet Use
System Level Recommendations
System-level considerations that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:
-Evaluate unit geography when planning for ADC installation or upgrades;
Minimize the potential for ADC users who stock and remove drugs, to be distracted while working at the ADC;
-Match ADC stock to unit needs meticulously, using unit-dose packaging whenever possible. Overstocking medications predisposes to wrong-dose errors, specifically overdoses, while stocking drugs that are not routinely used predisposes to wrong drug errors;
-Store drugs with look-alike, sound-alike names in different locations within ADCs. Consult published lists such as the ISMP's list of frequently confused drug names to determine which medications stored in each of the facility's ADCs pose the greatest potential to be mixed up in the selection process;
-Examine interdisciplinary workflow issues and eliminate scheduling conflicts so that routine drug stocking and retrieval activities do not overlap;
-Establish procedures for medication administration that avoid distractions related to other duties, especially in settings where nurses care for multiple patients.[4,5] Drug selection is a high-stakes activity, one that may be compared to safety-sensitive tasks that occur during pre-flight activities in the aviation industry. System leaders should evaluate expectations, especially those that involve multi-tasking, to ensure that staff members are not routinely disrupted at high-stakes junctures in medication administration. (If you wouldn't want the captain of your airliner to greet passengers while simultaneously performing pre-flight checks, you should advocate for processes that allow nurse to similar attention to detail during drug selection);
-Maximize the use of barcode technology with ADCs to make sure that the correct products (intended drug in the correct dose units or container size) are stocked in each clinical setting.[6] Bar-code product verification at point of retrieval (or point of administration) further diminishes the likelihood of wrong drug or wrong dose errors. When barcode verification is not possible, high alert drugs should be verified both by the person stocking the ADC and a unit-based nurse;
-Ensure that patient medication administration records (MAR) are accessible to practitioners while they are removing medications from an ADC. To make this a practice norm, select workstations that can be positioned near the ADC. When purchasing hardware (such as wheeled workstations), weigh cost-benefits of integrated patient information repositories in light of nursing time and patient safety. (The process used to deliver food to your table at the average chain restaurant should not be more reliable -- and less cumbersome -- than the process used to bring ordered medications to your bedside in a community hospital);
-The ADC should display drug information in a nonambiguous fashion, matching information provided on the MAR;
-Require pharmacy review of medication orders (which includes measures such as checking the order against known allergies; reviewing appropriateness of the prescribed dose; and evaluating potential for drug-drug interactions) prior to removal of medications, except in emergency situations.[6] Once pharmacy review has occurred, a readily identifiable flag/symbol should signal "go" to frontline clinicians;
-Use computerized alerts, ideally pop-ups that require a confirmation, when medications with high potential for mix-up (look-alike, sound-alike medications) in a given setting are selected. Bring the possibility of drug product confusion to the attention of the clinician at the point of retrieval, especially for other high alert drugs that have look-alike, sound-like qualities. For example, to minimize morphine and hydromorphone confusion risk, the ADC screen may prompt, "This is DILAUDID. Is that correct?" whenever hydromorphone is selected[7];
-Monitor how well ADCs, as configured, support care goals established by frontline providers and expected by patients and other stakeholders. This may be accomplished through proactive order set/clinical pathway review and retrospective review of medication overrides. Investigate causes of ADC overrides, considering the possibility of production pressure, especially in settings where turnover goals may compete with meticulous adherence to safest medication practices;
-Teach front line clinicians, especially those who participate in unit-based practice councils and multidisciplinary committees, the principles that inform safest use of ADCs, especially those that relate to medication stocking and availability. Solicit their input proactively to prepare for anticipated practice changes involving medication use and medication storage;
-Consider providing unit-based practice councils and multidisciplinary teams in specialty units to review ADC metrics (such as results of override reports). With this knowledge, it will be possible to identify deviations from targeted benchmarks, identify barriers to compliance, and champion safest practices;
-Ensure that knowledge of high alert medications and look-alike/sound-alike drugs (particular to a given clinical setting) are included in orientation and initial competency validation measures of individuals who dispense, stock, or administer medications; and
-Create a culture in which concerns voiced by frontline clinicians are seen as valuable. Develop a visible "rapid response" when ADC near-misses or discrepancies are reported.
Individual Level Recommendations
Considerations for individuals that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:
-Recognize that medication retrieval from ADCs is a high-risk activity, one in which human error has the potential to cause irreparable harm;
-Utilize bar-code scanning to the fullest extent possible in your practice setting. Report barriers to compliance immediately, using system-wide, near-miss reporting systems. For example, if barcode scanning is prevented by mechanical failures, battery life, or the availability of scanning equipment during high volume medication administration times -- these are reportable events;
-Upon removal of a drug from an ADC, validate that the drug name on the label of the drug-in-hand matches the drug name displayed on the patient's MAR (or prescriber's order if MAR has not been generated);
-Validate that the drug-in-hand is the ordered concentration, dose, and dosage form;
Be suspicious of any dose that would require removal of more than 3 packages/ampules/vials to administer a single dose;
-Avoid excessive use of the override function; it should be limited to true emergencies;
-Be aware that distractions undermine performance. Reduce distractions within your control when you are removing medications from ADCs. Although duties related to medication administration occupy a significant amount of nursing time, accurate performance cannot be assured simply because tasks are familiar. For example, answering cell phones while performing high-stakes activities impairs accuracy. Social exchanges with colleagues, patients, and family members should not occur at the ADC;
-Advocate for practice models that promote the least amount of distraction during medication preparation and administration. If multi-tasking while accessing medications from an ADC is a performance expectation, use professional practice councils and near-miss reporting systems to call attention to this risk;
-Become familiar with the rationale behind the system-level interventions (listed above) that promote safest use of ADCs; and
-Report deviations from ideal or standard practices as near-misses. This may seem "picky," but having a highly reliable medication use system involves meticulous attention to detail, something which requires a high degree of standardization. A system that has to undergo individual interpretation to accomplish routine tasks -- like a 9:00 am medication pass -- is error-prone. Fixing a system is difficult, but possible (in a way that fixing a lethal wrong-drug medication error is not). Here are a few things worth reporting when you notice them: A discrepancy between the way the drug name is displayed on the MAR and on the ADC screen; for example, when tall-man letters used to differentiate a known look-alike, sound-alike drug pair throughout your organization are not used on the pick list of your ADC screen; or when you find a syringe labeled "hydromorphone" in a bin labeled "morphine."
Summing Up: Seeing Beyond "The Box"
ADCs, particularly when they interface with computerized redundancies such as bar-coding and electronic MARS, give front line clinicians powerful tools to deliver reliable results. But reaping the benefits of technology involves more than selecting "the best box."
Knowledge of how automated dispensing cabinets are used by clinicians is essential for realizing the potential of these devices to improve safety, just as they have improved efficiency and charge capture for medications. Individual performance is one aspect of medication safety: how individuals perform is affected by the knowledge and competency each brings to the task at hand along with personal practice habits and choices under each individual's control. But key elements of performance are also influenced by the system in which care is delivered and by factors controlled at the organizational level.
To maximize the benefits of ADCs, organizations should identify and manage risk points that predictably occur when humans, often busy and working under stress, interface with machines to deliver high-stakes therapies. Interdisciplinary guidance, such as those published by ISMP, identify these risk-points and recommend risk-reduction strategies, enabling organizations to align work-flow and performance expectations so that the safety benefits of ADCs are fully realized.
Monday, June 29, 2009
Are Nurse Jackie and Hawthorne helping or harming nursing?
Thought I would forward this information on our Blog:
News Alert from the Center for Nursing Advocacy:
Nurse Jackie and HawthoRNe have created quite a stir in the nursing community, causing excitement about nurses being featured as lead characters on prime time television, but also concern about whether the character profiles and story lines will have a positive or negative impact on the public's understanding of who nurses are and what they do.
Center for Nursing Advocacy board members have been weighing in, and we would like to open a discussion with all of you on what has already become a source of controversy among nursing professionals. Suzanne Gordon, internationally known journalist, advocate for nurses, and a member of our Board of Directors, wrote an op-ed for the Boston Globe on the new shows, and Board chair Mary Dominiak was quoted in a Chicago Sun-Times article.
Please join the discussion at our discussion board. Our discussion board was recently reactivated after removing a deceptive thread started by an unauthorized person who posted false information about the Center's status. Now, we invite your thoughts on the following topics:
Are Nurse Jackie and HawthoRNe harming or helping nursing?
How can nurses, including nursing faculty, use Nurse Jackie and HawthoRNe to educate their peers and students about the importance of becoming advocates for the nursing profession?
We look forward to the discussion!
News Alert from the Center for Nursing Advocacy:
Nurse Jackie and HawthoRNe have created quite a stir in the nursing community, causing excitement about nurses being featured as lead characters on prime time television, but also concern about whether the character profiles and story lines will have a positive or negative impact on the public's understanding of who nurses are and what they do.
Center for Nursing Advocacy board members have been weighing in, and we would like to open a discussion with all of you on what has already become a source of controversy among nursing professionals. Suzanne Gordon, internationally known journalist, advocate for nurses, and a member of our Board of Directors, wrote an op-ed for the Boston Globe on the new shows, and Board chair Mary Dominiak was quoted in a Chicago Sun-Times article.
Please join the discussion at our discussion board. Our discussion board was recently reactivated after removing a deceptive thread started by an unauthorized person who posted false information about the Center's status. Now, we invite your thoughts on the following topics:
Are Nurse Jackie and HawthoRNe harming or helping nursing?
How can nurses, including nursing faculty, use Nurse Jackie and HawthoRNe to educate their peers and students about the importance of becoming advocates for the nursing profession?
We look forward to the discussion!
Wednesday, June 17, 2009
Nurse Jackie
Click on link above to find out more about this showtime series. Within the link are also spoilers and clips.enjoy!
Thursday, June 4, 2009
MRSA
Methicillin-resistant staphylococcus aureus (MRSA) is a micro-organism that has developed a resistance to antibiotics. MRSA is currently the most clinically significant antibiotic-resistant organism (ARO) in Canada.
MRSA is hardy. The bacteria can live up to six weeks on environmental surfaces and is easily transmitted by skin-to-skin contact and touching shared items. Through the implementation of evidence-based strategies, healthcare providers can reduce MRSA transmission and infections.
About 220,000 Canadians develop hospital-acquired infections each year and about 8,000 die from them annually. It costs more to treat MRSA infections than to prevent them. Estimated costs for treating and isolating patients with MRSA infections was $82 million in 2004 and that could reach $129 million by 2010. Total cost per infected MRSA patient averages $12,216, for prolonged hospitalization, special control measures, expensive treatments and extensive surveillance.
The five key components of evidence-based infection control practices that form the basis of successfully reducing MRSA transmission include an aggressive hand hygiene program; systematic cleaning and decontamination of the environment and equipment; precautions for contact with any patient that is infected with MRSA; selected MRSA screening surveillance cultures on admission and at other times during hospitalization if indicated; and regularly reporting of MRSA infection rates to frontline workers and hospital leadership. Participation in this intervention can help your organization meet the MRSA reporting requirements of the Canadian Council on Health Services Accreditation.
MRSA is hardy. The bacteria can live up to six weeks on environmental surfaces and is easily transmitted by skin-to-skin contact and touching shared items. Through the implementation of evidence-based strategies, healthcare providers can reduce MRSA transmission and infections.
About 220,000 Canadians develop hospital-acquired infections each year and about 8,000 die from them annually. It costs more to treat MRSA infections than to prevent them. Estimated costs for treating and isolating patients with MRSA infections was $82 million in 2004 and that could reach $129 million by 2010. Total cost per infected MRSA patient averages $12,216, for prolonged hospitalization, special control measures, expensive treatments and extensive surveillance.
The five key components of evidence-based infection control practices that form the basis of successfully reducing MRSA transmission include an aggressive hand hygiene program; systematic cleaning and decontamination of the environment and equipment; precautions for contact with any patient that is infected with MRSA; selected MRSA screening surveillance cultures on admission and at other times during hospitalization if indicated; and regularly reporting of MRSA infection rates to frontline workers and hospital leadership. Participation in this intervention can help your organization meet the MRSA reporting requirements of the Canadian Council on Health Services Accreditation.
Video's on HAI and MRSA
For some really interesting video information regarding HAI's and MRSA, please click the link below.
Wednesday, May 20, 2009
Beware of basal opiod infusions with PCA therapy
Medication Safety
ISMP Reports:
Problem: A 63-year-old, 109 kg, opioid-naïve patient was admitted to a hospital with fractures sustained in a fall. She was given two doses of morphine 4 mg and one dose of HYDROmorphone 1 mg in the emergency department.
Upon arrival to the inpatient unit, she was started on HYDROmorphone PCA (patient controlled analgesia), which included a basal infusion of 0.5 mg per hour, a demand dose of 0.2 mg with a lockout interval of 10 minutes, and a 4 hour limit of 6 mg. Continuous pulse oximetry was not in use. Five hours later, the patient was found unresponsive. Her respirations were six per minute, and her nail beds were beginning to turn blue. Oxygen saturation was checked with pulse oximetry and found to be 44%. The rapid response team was called, oxygen was started, and two doses of naloxone were administered. In 15 minutes, the patient was alert and talking. It was then that the patient told a nurse she has sleep apnea and had previously used a continuous positive airway pressure (CPAP) machine at home. She hadn’t been using the CPAP recently. So, when the admitting nurse asked her if she used any medical equipment at home, she said “No.”
The patient’s body mass index (BMI) was 38.6 (BMI of 40 or more is morbid obesity), placing her at risk for sleep apnea and hypoxemia during PCA therapy.Although no permanent harm ensued, the hospital’s medication safety team used this case as a learning opportunity. Three root causes of the event were identified, as described below.
Dosing guidance. The PCA standard order form did not help guide prescribers to appropriate doses; instead, it provided a broad range of doses. For example, the range for a HYDROmorphone basal infusion dose was 0.1 to 0.5 mg/hour, and there was no guidance for selecting appropriate candidates for basal infusions. Many prescribers routinely selected a 0.5 mg/hour basal infusion, regardless of patient characteristics. A basal opioid infusion was not appropriate for this opioid-naïve patient.Studies have shown that patients with basal opioid infusions are at least five times more likely to experience respiratory depression.(1-4) The American Pain Society cautions against using continuous basal infusions because studies have failed to demonstrate significant differences in the quality of analgesia with or without basal infusions.(4) There may also be an increased risk of programming errors when basal infusions are prescribed.(5)
Patient screening. The patient was not sufficiently screened for obstructive sleep apnea (OSA) and other risk factors for PCA-induced respiratory depression. The facility had an OSA screening process in place for pre-operative patients, but screening did not occur because this patient was not a surgical candidate. The incidence of respiratory depression in PCA patients ranges from 0.19 to 5.2 percent, depending on how it is measured.(1-4) Figure 1 (in the PDF version of the newsletter) includes risk factors for respiratory depression in PCA patients.
Patient monitoring. No process was in place to trigger an evaluation of the need for continuous pulse oximetry monitoring (or capnography for appropriate patients) during PCA.
Safe Practice Recommendations: The hospital’s medication safety team addressed these root causes by standardizing the PCA dosing process and revising the standard PCA order form as described below.---Prescribers are guided to an appropriate dose based on age and opioid tolerance by providing default doses for three types of patients: most patients, patients over 64 years or with sleep apnea, and opioid-tolerant patients (see Figure 2 in the PDF version of the newsletter).---Basal infusions were eliminated except in opioid-tolerant patients.---Basal infusions in patients with sleep apnea were prohibited.---Opioid orders were rearranged to match the sequence in which the medications appear on the facility’s smart IV pumps.---A registered nurse is required to screen the patient for OSA before PCA initiation, with further assessment by a respiratory therapist if the screening shows two or more risk factors (see Figure 3 in the PDF version of the newsletter).---Continuous pulse oximetry (or capnography if appropriate) is required while on PCA if the patient has a continuous opioid infusion or sleep apnea, or if the patient is morbidly obese or older than 64 years.---Patient education is required and must include instructions to the patient’s family not to push the PCA button for the patient (PCA by proxy).The hospital also uses smart pumps for PCA therapy, with one standardized concentration for each drug and dose limits set in the pump library. Before converting to smart pumps, two PCA programming errors had occurred in recent years, leading to serious respiratory depression. Vast improvements in programming accuracy have been reported since switching to the smart pumps.
In our February 22, 2007 newsletter (www.ismp.org/Newsletters/acutecare/articles/20070222.asp), we recommended avoiding basal infusions unless the patient is opioid-tolerant. Unfortunately, the term “opioid-tolerant” is not well understood. It is defined as “those patients who have received opioids regularly for approximately 7 days or more.” Opioid-naïve patients who present with high opioid requirements may be an exception and require a basal infusion, but additional safety steps should be instituted under these conditions. Our July 24, 2003, newsletter includes many recommendations to improve PCA safety, including the following.---Evaluate the patient’s level of pain, alertness, and vital signs, including rate and quality of respirations, every 2-4 hours.---Evaluate patients with minimal verbal and tactile stimulation to obtain an accurate assessment of their level of sedation.---Monitor patients more frequently during the first 24 hours and at night, when hypoventilation and nocturnal hypoxia may occur.---Employ early warning devices such as apnea alarms at night and pulse oximetry or capnography, which can alert practitioners to respiratory insufficiency.Additional recommendations related to safe PCA use can be found in our July 24, 2003 newsletter (www.ismp.org/Newsletters/acutecare/articles/20030724.asp).
References1) Hagle M. Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthopaedic Nursing 2004;23:18-29.2) McCaffery M, Pasero C. Pain: Clinical Manual (2nd ed.). Boston : Mosby, 1999.3) Weber L. Implementation of standard order sets for patient controlled analgesia. Am J Health-Syst Pharm 2008;65:1184-91.4) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th ed.). Glenview , IL : American Pain Society, 2003.5) Ashburn M, Love G, Pace N. Respiratory related critical events with patient-controlled analgesia. Clin J Pain 1994;10:52-56.
ISMP Reports:
Problem: A 63-year-old, 109 kg, opioid-naïve patient was admitted to a hospital with fractures sustained in a fall. She was given two doses of morphine 4 mg and one dose of HYDROmorphone 1 mg in the emergency department.
Upon arrival to the inpatient unit, she was started on HYDROmorphone PCA (patient controlled analgesia), which included a basal infusion of 0.5 mg per hour, a demand dose of 0.2 mg with a lockout interval of 10 minutes, and a 4 hour limit of 6 mg. Continuous pulse oximetry was not in use. Five hours later, the patient was found unresponsive. Her respirations were six per minute, and her nail beds were beginning to turn blue. Oxygen saturation was checked with pulse oximetry and found to be 44%. The rapid response team was called, oxygen was started, and two doses of naloxone were administered. In 15 minutes, the patient was alert and talking. It was then that the patient told a nurse she has sleep apnea and had previously used a continuous positive airway pressure (CPAP) machine at home. She hadn’t been using the CPAP recently. So, when the admitting nurse asked her if she used any medical equipment at home, she said “No.”
The patient’s body mass index (BMI) was 38.6 (BMI of 40 or more is morbid obesity), placing her at risk for sleep apnea and hypoxemia during PCA therapy.Although no permanent harm ensued, the hospital’s medication safety team used this case as a learning opportunity. Three root causes of the event were identified, as described below.
Dosing guidance. The PCA standard order form did not help guide prescribers to appropriate doses; instead, it provided a broad range of doses. For example, the range for a HYDROmorphone basal infusion dose was 0.1 to 0.5 mg/hour, and there was no guidance for selecting appropriate candidates for basal infusions. Many prescribers routinely selected a 0.5 mg/hour basal infusion, regardless of patient characteristics. A basal opioid infusion was not appropriate for this opioid-naïve patient.Studies have shown that patients with basal opioid infusions are at least five times more likely to experience respiratory depression.(1-4) The American Pain Society cautions against using continuous basal infusions because studies have failed to demonstrate significant differences in the quality of analgesia with or without basal infusions.(4) There may also be an increased risk of programming errors when basal infusions are prescribed.(5)
Patient screening. The patient was not sufficiently screened for obstructive sleep apnea (OSA) and other risk factors for PCA-induced respiratory depression. The facility had an OSA screening process in place for pre-operative patients, but screening did not occur because this patient was not a surgical candidate. The incidence of respiratory depression in PCA patients ranges from 0.19 to 5.2 percent, depending on how it is measured.(1-4) Figure 1 (in the PDF version of the newsletter) includes risk factors for respiratory depression in PCA patients.
Patient monitoring. No process was in place to trigger an evaluation of the need for continuous pulse oximetry monitoring (or capnography for appropriate patients) during PCA.
Safe Practice Recommendations: The hospital’s medication safety team addressed these root causes by standardizing the PCA dosing process and revising the standard PCA order form as described below.---Prescribers are guided to an appropriate dose based on age and opioid tolerance by providing default doses for three types of patients: most patients, patients over 64 years or with sleep apnea, and opioid-tolerant patients (see Figure 2 in the PDF version of the newsletter).---Basal infusions were eliminated except in opioid-tolerant patients.---Basal infusions in patients with sleep apnea were prohibited.---Opioid orders were rearranged to match the sequence in which the medications appear on the facility’s smart IV pumps.---A registered nurse is required to screen the patient for OSA before PCA initiation, with further assessment by a respiratory therapist if the screening shows two or more risk factors (see Figure 3 in the PDF version of the newsletter).---Continuous pulse oximetry (or capnography if appropriate) is required while on PCA if the patient has a continuous opioid infusion or sleep apnea, or if the patient is morbidly obese or older than 64 years.---Patient education is required and must include instructions to the patient’s family not to push the PCA button for the patient (PCA by proxy).The hospital also uses smart pumps for PCA therapy, with one standardized concentration for each drug and dose limits set in the pump library. Before converting to smart pumps, two PCA programming errors had occurred in recent years, leading to serious respiratory depression. Vast improvements in programming accuracy have been reported since switching to the smart pumps.
In our February 22, 2007 newsletter (www.ismp.org/Newsletters/acutecare/articles/20070222.asp), we recommended avoiding basal infusions unless the patient is opioid-tolerant. Unfortunately, the term “opioid-tolerant” is not well understood. It is defined as “those patients who have received opioids regularly for approximately 7 days or more.” Opioid-naïve patients who present with high opioid requirements may be an exception and require a basal infusion, but additional safety steps should be instituted under these conditions. Our July 24, 2003, newsletter includes many recommendations to improve PCA safety, including the following.---Evaluate the patient’s level of pain, alertness, and vital signs, including rate and quality of respirations, every 2-4 hours.---Evaluate patients with minimal verbal and tactile stimulation to obtain an accurate assessment of their level of sedation.---Monitor patients more frequently during the first 24 hours and at night, when hypoventilation and nocturnal hypoxia may occur.---Employ early warning devices such as apnea alarms at night and pulse oximetry or capnography, which can alert practitioners to respiratory insufficiency.Additional recommendations related to safe PCA use can be found in our July 24, 2003 newsletter (www.ismp.org/Newsletters/acutecare/articles/20030724.asp).
References1) Hagle M. Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthopaedic Nursing 2004;23:18-29.2) McCaffery M, Pasero C. Pain: Clinical Manual (2nd ed.). Boston : Mosby, 1999.3) Weber L. Implementation of standard order sets for patient controlled analgesia. Am J Health-Syst Pharm 2008;65:1184-91.4) Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th ed.). Glenview , IL : American Pain Society, 2003.5) Ashburn M, Love G, Pace N. Respiratory related critical events with patient-controlled analgesia. Clin J Pain 1994;10:52-56.
Monday, March 30, 2009
Saving Lives
Last year, at the ASPAN Conference held in Grapevine, TX, the opening speaker talked for almost an hour about the negative media portrayal of nurses in popular television programmes that include Soap Operas, prime time TV shows such as House and Gray's Anatomy, Scrubs and many more. At the time, there were many people in the audience who spoke up and expressed their opinion that it was 'entertainment', 'nobody believed it to be truth' and that 'some people take themselves too seriously.' I tended to side with them, but then I found a site called The Truth About Nursing which I found to be very interesting. I think my opinion has shifted somewhat. Why can't television programmes be entertaining AND factual? For years it has been driving me crazy that a patient on Life Support is intubated and talking with the side rails down, or on nasal prongs and 'close to death.' One time, I think it was on the Y&R, a young child on life support (and nasal prongs) died while the nurse was just standing there, sadly watching the child die. No CPR, no attempt at any kind of calling out for help...just the thin annoying pitch of a flat line on the monitor. That's just one example.
Anyway, it's food for thought. We all know the important work that we do, and that hospitals around the world could not function without Nurses. Isn't it time that we get the respect that is due?
If you are interested in reading more about this, here is a book that is being promoted by The Truth About Nursing:
Saving Lives: Why the Medias Portrayal of Nurses puts us all at Risk
Anyway, it's food for thought. We all know the important work that we do, and that hospitals around the world could not function without Nurses. Isn't it time that we get the respect that is due?
If you are interested in reading more about this, here is a book that is being promoted by The Truth About Nursing:
Saving Lives: Why the Medias Portrayal of Nurses puts us all at Risk
Information from the dust jacket of Saving Lives:
Popular TV shows like Grey’s Anatomy, ER, and House lead people to think that nurses simply push gurneys, drive romantic plots, and provide a human backdrop for the real action. However, those of us among the 12 million nurses worldwide know the reality is far more fascinating, demanding and important.
Written by the leaders of The Truth About Nursing, the organization at the forefront of challenging and changing representations of nurses, Saving Lives highlights the essential role nurses play. It explores the public’s perception of nurses and spells out the greatest myths about nursing, drawing on examples from television shows, ads, news, and other media.
Saving Lives exposes the media’s role in reinforcing stereotypes that help fuel the nursing shortage. But it is also a call to action. Saving Lives offers concrete steps to help nurses and their supporters educate the public about nursing.
For millions of people worldwide, nurses are the difference between life and death, self-sufficiency and dependency, and hope and despair. Nonetheless a lack of appreciation for nursing has contributed to a global shortage that is one of our most urgent public health crises. There are not enough nurses available to monitor patients, provide high-tech treatments, advocate for patients, and teach patients how to live with their conditions. Poor understanding of what nurses do undermines claims for adequate staffing, and leads to a lack of resources for nursing practice, education, and research. All of that means worse patient outcomes, including death.
Saving Lives is destined to change public perceptions, thereby empowering nurses and helping them get the respect they need to save lives.
Popular TV shows like Grey’s Anatomy, ER, and House lead people to think that nurses simply push gurneys, drive romantic plots, and provide a human backdrop for the real action. However, those of us among the 12 million nurses worldwide know the reality is far more fascinating, demanding and important.
Written by the leaders of The Truth About Nursing, the organization at the forefront of challenging and changing representations of nurses, Saving Lives highlights the essential role nurses play. It explores the public’s perception of nurses and spells out the greatest myths about nursing, drawing on examples from television shows, ads, news, and other media.
Saving Lives exposes the media’s role in reinforcing stereotypes that help fuel the nursing shortage. But it is also a call to action. Saving Lives offers concrete steps to help nurses and their supporters educate the public about nursing.
For millions of people worldwide, nurses are the difference between life and death, self-sufficiency and dependency, and hope and despair. Nonetheless a lack of appreciation for nursing has contributed to a global shortage that is one of our most urgent public health crises. There are not enough nurses available to monitor patients, provide high-tech treatments, advocate for patients, and teach patients how to live with their conditions. Poor understanding of what nurses do undermines claims for adequate staffing, and leads to a lack of resources for nursing practice, education, and research. All of that means worse patient outcomes, including death.
Saving Lives is destined to change public perceptions, thereby empowering nurses and helping them get the respect they need to save lives.
The "Not What They Say I Am" flyer sends a message that many media depictions of nurses are not accurate and that nurses object to them, in part because they undermine nurses' claims to adequate resources. This is a key message of the Truth About Nursing, and one explored in detail in our new book Saving Lives.
The ironic "Hooray for Hollywood" flyer sends the message that, in our view, there has been little for nurses to cheer about in recent Hollywood depictions of their work. Popular TV shows like "House" and "Grey's Anatomy" have repeatedly offered inaccurate and damaging images of nursing, and we hope the flyer will cause those who see it to reconsider those images. The small print on the flyers directs people to our book and The Truth's website.
Find more information at http://www.truthaboutnursing.org/
I'll throw the question to you. Do you think that the media's portrayal of nurses is disrespectful and highly inaccurate, or do you think it's all just entertainment and there shouldn't be a big deal made about it?Thursday, March 12, 2009
Opinion - 'Do we really need all these nurses?'
Opinion - 'Do we really need all these nurses?'Toronto Star, March 10, 2009
Sioban Nelson
If there's one thing nurses know, it's that tough economic times tend to mean cuts to the profession. This has been the pattern over the decades, where nursing from Toronto to Manchester to São Paulo has all too frequently been the health-care service sector that takes the hardest and deepest cuts when the economy takes a nose dive.
There is an obvious reason for this. Nursing salaries account for a major percentage of health-service budgets. As CEOs and CFOs are driven to reduce spending and create efficiencies, the first question that comes to mind is usually: "Do we really need all these nurses?"
This is at one level a legitimate question. The drive to answer it has spawned an entire science that measures workload and efficiency, examines the relationship between the number and skill level of nurses on patient outcomes, and analyzes the relationship between staffing profile turnover and burnout.
The Lawrence S. Bloomberg Faculty of Nursing, through its nursing research unit and faculty research, has made this faculty one of the top sites in the world for health-services research in nursing and health care.
But the question "Do we really need all these nurses?" is not only an empirical one that good research can answer. It is also a rhetorical question that reflects a worrying attitude toward nursing that has bedevilled the profession for more than a century.
Even today, when we finally have the data to show that quality nursing staff is strongly correlated with patient outcomes (including mortality), the question continues to be raised. The tradition of seeing nursing as a resource to be built up in good times and trimmed back in lean times dates back to the very beginning of professional nursing.
For most of the 20th century, nursing-student labour fuelled the engines of the modern hospital. Hospitals hummed with industrious nurses washing patients, bed-making and establishing military order and cleanliness. Behind the scenes, student nurses rolled bandages, mended surgical gloves, sterilized and packaged all the sterile materials and packs, sorted laundry items, stocked and restocked drugs and supplies, cooked special diet meals in ward kitchens, distributed all meals and fed all patients. Nurses managed the wards, their patients, the operating room, the hospital budgets and overall operations.
There was clinical work, too. Early transfusions involved six nurses managing the two patients, careful handling of the delicate glass equipment and ensuring constant flow to prevent clotting. Hypodermic injections involved oil-lamp heating of solutions, and nurses did a great deal of dispensing work in the everyday course of caring for their patients. Pre-antibiotic era nursing meant lengthy and complex irrigations of wounds and douchings.
When students graduated from their programs and completed their staff nurse year, they made their way into the few senior roles that existed within the hospital sector or moved into the community, public health and home-nursing sector, where experienced nurses held their own.
Back in the hospitals, the priority often was volume rather than quality. Young girls were worked hard and long with poor remuneration and little respect for their contribution to patient care. High burnout rates, workplace injuries and poor health status have been the norm for hospital-based nurses around the world for far too long.
It also has led to the idea that nurses are in a sense a disposable resource, replaceable and interchangeable like front-line soldiers in early 20th century warfare. Despite clear advances in nursing's position in many parts of the world, including Canada, with each turn of the economic screw, nurses feel the vulnerability of the sector.
Every time we cut nurses, we hit a pipeline. It is not today's nurses we affect but the next 10 years' worth of nurses. In five years' time, with normal attrition and the retirement of the boomers, there will inevitably be more panicked calls for nurses - but where will they be?
Every time nursing jobs are cut, smart young high-school students watch and learn. They choose other careers. Meanwhile, health-service providers cut services and shed nurses. Overwhelmed services can't cope with the demands of students. They cut places. So when the pendulum swings it is impossible to increase the number of nursing student seats.
Meanwhile, entrepreneurial governments and private providers scour the world for nurses, causing more inequity and suffering in their wake as they contract large numbers of nurses from countries that can ill afford to lose them.
What are the implications for health care with today's economic crisis? The rise in chronic illness along with the aging RN workforce make this a critical moment for the future of our health-care system. If we cut off nurses now, we will feel it for the next decade and beyond -and it will be bad.
Do we really need all these nurses? We do.
We need new graduates developing their skills and knowledge in a safe and supportive environment so they do not burn out and leave. We need advanced practice nurses bringing creative and cost-effective solutions to complex system problems. We need nurse practitioners to provide access to the great number of people the system currently fails and to keep costs down. We need them to prevent illness, manage chronic disease and to keep people well and safe in the community. We need them to track us through the highly dangerous space of the acute in-patient sector and ensure that we avoid life-threatening complications, are well-informed and educated about our treatment and its consequences, and go home in the best position possible to undertake self-management of chronic conditions.
To cut nurses is to cut the system's capacity to do this now and into the future. It is in everyone's interest to make sure our decision-makers understand this and are held accountable for the consequences of their actions. As members of the profession and members of the public, it is our job to ensure this.
Sioban Nelson is dean of the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Sheree BondPublic Relations TeamOntario Nurses' Association85 Grenville Street, Suite 400Toronto, ON M5S 3A2(416) 964-8833, ext. 2430
Tuesday, March 10, 2009
Inattentional Blindness: What Captures Your Attention?
ISMP (United States) Medication Safety Alert! Febuary 26, 2009 Vol. 14, Issue 4
Inattentional Blindness: What Captures Your Attention?
A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies.
A pharmacist enters a prescription for methotrexate daily into the pharmacy computer. A dose warning appears on the screen. The pharmacist reads the warning, bypasses it, and dispenses the medication as entered. The patient receives an overdose of the medication and dies.
A nurse reaches in the refrigerator for a piggyback antibiotic for her patient. She reads the label, spikes the bag with IV tubing, and administers the medication to her patient. The patient receives a neuromuscular blocking agent instead of the intended antibiotic and dies.
A pharmacy technician labels and delivers an IV infusion to the dialysis unit. The nurse reads the pharmacy label and hangs the bag while preparing her patient for dialysis. The patient receives sterile water for injection instead of 0.9% sodium chloride and dies.
A nurse picks out a prefilled syringe of pain medication for her patient. She reads the label and administers the medication intravenously. The patient receives hydromorphone instead of morphine and experiences a respiratory arrest.
All of these actual errors, and many more in healthcare and other industries, have happened under similar circumstances: the person performing the task fails to see what should have been plainly visible, and later, they cannot explain the lapse.(1) In many cases, people involved in the errors have been labeled as careless and negligent. But these types of accidents are common—even with intelligent, vigilant, and attentive people. The cause is usually rooted in inattentional blindness, a condition all people periodically exhibit.(1)
How do we process information?
Most mental processing occurs outside of conscious awareness. The amount of information that can be taken in by our senses is limitless. But the brain has very limited resources when it comes to attentiveness. Our senses receive much more information than can possibly be processed at one time. To combat information overload, the brain allows large amounts of information through almost entirely unassimilated, peeling off just a few pieces of selected information for a closer look.(2)
In deciding what to focus on, the brain scans about 30-40 pieces of information (e.g., sights, sounds, smells, tactile information) per second, until something captures its attention.(2) Our attention filter selects just a small amount of information to process, and anything leftover gets short shrift. The rest of the information never reaches our consciousness—thus the term inattentional blindness. Unfortunately, the brain is a master at filling in the gaps and compiling an integrated portrait of reality based on just a flickering view.(1)
Accidents happen when attention mistakenly filters away important information and the brain fills in the gaps with what is aptly referred to as a “grand illusion.” (2) Thus, in the examples above, the brains of the individuals involved in the errors filtered out important information on medication labels and computer screens, and filled in the gaps with erroneous information that led them to believe they had the correct medication or had read the warning appropriately.
What captures your attention?
Visual attentiveness, or what captures your attention, is shaped by four factors.
Conspicuity. The degree to which an object or piece of information jumps out to capture your attention falls into two categories: sensory conspicuity and cognitive conspicuity. Sensory conspicuity deals with the physical properties of information. For example, a high degree of contrast with the background is the most important feature in making information conspicuous,(1) and luminance (brightness) contrast is more important than color contrast.(3) Factors such as bright colors, movement, and flicker do not ensure conspicuity;(1) however, pre-attentive properties (the brain automatically processes the information without being aware of it) such as color and shape have been used successfully on visual displays to call attention to specific items or categories.(3)
Cognitive conspicuity deals with the perceived relevance of the information. The “cocktail party” effect(4) is a classic portrayal of this factor. This is the term used for the phenomenon of being in a crowd, listening to a conversation, and still being able to hear your name mentioned across the room.(3) Functioning somewhat like the volume control on a radio, you can turn down the volume of background noise at a cocktail party and turn up the volume as you listen attentively to one conversation at a time. While engaged in conversation, if someone behind you mentions your name, you are automatically attracted to the other conversation because it is meaningful to you. Meaningful visual information can also jump out at you automatically, such as scanning the newspaper and finding your attention drawn to articles that include the first name of your child. Attention to something of particular relevance can also be purposeful. For example, you may scan a luggage carousel for your black suitcase, looking purposefully for the broken wheel or yellow ribbon that distinguishes your suitcase from all the other black suitcases on the carousel.
Mental workload and task interference.
Inattentional blindness is more likely to occur if part of your attention is diverted to secondary tasks, like answering the phone while entering prescriptions into the computer, or even thinking about your dinner plans while transcribing an order. We all learn to function amazingly well while multi-tasking, but more complicated tasks require our full attention. However, auditory tasks (listening to the radio) will interfere less with visual tasks (seeing a pedestrian crossing the road) than would a second visual task (focusing on a street sign).(1)
Low workload causes boredom and reduces the mental attention given to tasks, as does carrying out highly practiced tasks, such as drawing medication out of a vial into a syringe. In fact, we spend a large majority of our waking life functioning with the equivalent of an automatic pilot, with occasional conscious checks to ensure tasks are being carried out properly. This makes us particularly prone to inattentional blindness. Reliance on technology has also lessened our ability to notice abnormalities.
Expectation.
Expectation has a powerful effect on our ability to pay attention and notice information. If the medication we are looking for comes in a carton with a highly stylized label, we come to expect this presentation every time we look for the medication. If a new medication comes in a similar looking carton, our brain may not pay attention to any information that disconfirms our belief that the new medication is the old one—a well-known phenomenon called confirmation bias to which highly experienced practitioners are most prone.
Our past experiences also teach us what is relevant. Errors occur when new or unusual circumstances happen in highly familiar situations. The nurse who picked up a vial of heparin in the wrong concentration had never experienced removing the wrong medication from an ADC cabinet before this event. The pharmacist who did not notice important information on a computer warning had rarely encountered a clinically significant computer alert. The nurse who picked the wrong pain medication from the narcotics cabinet did not remember making such an error in the past. Each of the practitioners in the examples above had subconsciously learned that there was nothing important to see when carrying out these tasks. Nothing had ever happened, so attention was automatically filtered away from the details to conserve mental processing.
Capacity.
The capacity to pay attention is variable from person to person and influenced by age and mental aptitude. From time to time, attention is also variable within an individual due to influences such as distractions, alcohol, drugs, and fatigue.
It is difficult to reduce the risk of inattentional blindness, as it is an involuntary and unnoticed consequence of our adaptive ability to defend against information overload. Error-reduction strategies such as education, training, and rules are of little value. Instead, efforts should center on increasing conspicuity of critical information, and decreasing diversions of attention and secondary tasks when carrying out complex tasks.
References: 1) Green M. “Inattentional blindness” and conspicuity. Visual Expert 2004 (www.visualexpert.com/Resources/inattentionalblindness.ht ml). 2) Angier N. Blind to change, even as it stares us in the face. The New York Times April 1, 2008 (www.nytimes.com/200 8/04/01/science/01angi.htm?_r=2&ex=1207713600&en=204&oref=slogin). 3) Federal Aviation Administration (FAA). FAA human factors awareness course. (www.hf.faa.gov/webtraining/Intro/Intro1.htm). 4) Arons B. A review of the cocktail party effect. MIT Media Lab; 1992. (www.media.mit.edu/speech/paper s/1992/arons_AVIOSJ92_cocktail_party_effect.pdf).
Inattentional Blindness: What Captures Your Attention?
A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies.
A pharmacist enters a prescription for methotrexate daily into the pharmacy computer. A dose warning appears on the screen. The pharmacist reads the warning, bypasses it, and dispenses the medication as entered. The patient receives an overdose of the medication and dies.
A nurse reaches in the refrigerator for a piggyback antibiotic for her patient. She reads the label, spikes the bag with IV tubing, and administers the medication to her patient. The patient receives a neuromuscular blocking agent instead of the intended antibiotic and dies.
A pharmacy technician labels and delivers an IV infusion to the dialysis unit. The nurse reads the pharmacy label and hangs the bag while preparing her patient for dialysis. The patient receives sterile water for injection instead of 0.9% sodium chloride and dies.
A nurse picks out a prefilled syringe of pain medication for her patient. She reads the label and administers the medication intravenously. The patient receives hydromorphone instead of morphine and experiences a respiratory arrest.
All of these actual errors, and many more in healthcare and other industries, have happened under similar circumstances: the person performing the task fails to see what should have been plainly visible, and later, they cannot explain the lapse.(1) In many cases, people involved in the errors have been labeled as careless and negligent. But these types of accidents are common—even with intelligent, vigilant, and attentive people. The cause is usually rooted in inattentional blindness, a condition all people periodically exhibit.(1)
How do we process information?
Most mental processing occurs outside of conscious awareness. The amount of information that can be taken in by our senses is limitless. But the brain has very limited resources when it comes to attentiveness. Our senses receive much more information than can possibly be processed at one time. To combat information overload, the brain allows large amounts of information through almost entirely unassimilated, peeling off just a few pieces of selected information for a closer look.(2)
In deciding what to focus on, the brain scans about 30-40 pieces of information (e.g., sights, sounds, smells, tactile information) per second, until something captures its attention.(2) Our attention filter selects just a small amount of information to process, and anything leftover gets short shrift. The rest of the information never reaches our consciousness—thus the term inattentional blindness. Unfortunately, the brain is a master at filling in the gaps and compiling an integrated portrait of reality based on just a flickering view.(1)
Accidents happen when attention mistakenly filters away important information and the brain fills in the gaps with what is aptly referred to as a “grand illusion.” (2) Thus, in the examples above, the brains of the individuals involved in the errors filtered out important information on medication labels and computer screens, and filled in the gaps with erroneous information that led them to believe they had the correct medication or had read the warning appropriately.
What captures your attention?
Visual attentiveness, or what captures your attention, is shaped by four factors.
Conspicuity. The degree to which an object or piece of information jumps out to capture your attention falls into two categories: sensory conspicuity and cognitive conspicuity. Sensory conspicuity deals with the physical properties of information. For example, a high degree of contrast with the background is the most important feature in making information conspicuous,(1) and luminance (brightness) contrast is more important than color contrast.(3) Factors such as bright colors, movement, and flicker do not ensure conspicuity;(1) however, pre-attentive properties (the brain automatically processes the information without being aware of it) such as color and shape have been used successfully on visual displays to call attention to specific items or categories.(3)
Cognitive conspicuity deals with the perceived relevance of the information. The “cocktail party” effect(4) is a classic portrayal of this factor. This is the term used for the phenomenon of being in a crowd, listening to a conversation, and still being able to hear your name mentioned across the room.(3) Functioning somewhat like the volume control on a radio, you can turn down the volume of background noise at a cocktail party and turn up the volume as you listen attentively to one conversation at a time. While engaged in conversation, if someone behind you mentions your name, you are automatically attracted to the other conversation because it is meaningful to you. Meaningful visual information can also jump out at you automatically, such as scanning the newspaper and finding your attention drawn to articles that include the first name of your child. Attention to something of particular relevance can also be purposeful. For example, you may scan a luggage carousel for your black suitcase, looking purposefully for the broken wheel or yellow ribbon that distinguishes your suitcase from all the other black suitcases on the carousel.
Mental workload and task interference.
Inattentional blindness is more likely to occur if part of your attention is diverted to secondary tasks, like answering the phone while entering prescriptions into the computer, or even thinking about your dinner plans while transcribing an order. We all learn to function amazingly well while multi-tasking, but more complicated tasks require our full attention. However, auditory tasks (listening to the radio) will interfere less with visual tasks (seeing a pedestrian crossing the road) than would a second visual task (focusing on a street sign).(1)
Low workload causes boredom and reduces the mental attention given to tasks, as does carrying out highly practiced tasks, such as drawing medication out of a vial into a syringe. In fact, we spend a large majority of our waking life functioning with the equivalent of an automatic pilot, with occasional conscious checks to ensure tasks are being carried out properly. This makes us particularly prone to inattentional blindness. Reliance on technology has also lessened our ability to notice abnormalities.
Expectation.
Expectation has a powerful effect on our ability to pay attention and notice information. If the medication we are looking for comes in a carton with a highly stylized label, we come to expect this presentation every time we look for the medication. If a new medication comes in a similar looking carton, our brain may not pay attention to any information that disconfirms our belief that the new medication is the old one—a well-known phenomenon called confirmation bias to which highly experienced practitioners are most prone.
Our past experiences also teach us what is relevant. Errors occur when new or unusual circumstances happen in highly familiar situations. The nurse who picked up a vial of heparin in the wrong concentration had never experienced removing the wrong medication from an ADC cabinet before this event. The pharmacist who did not notice important information on a computer warning had rarely encountered a clinically significant computer alert. The nurse who picked the wrong pain medication from the narcotics cabinet did not remember making such an error in the past. Each of the practitioners in the examples above had subconsciously learned that there was nothing important to see when carrying out these tasks. Nothing had ever happened, so attention was automatically filtered away from the details to conserve mental processing.
Capacity.
The capacity to pay attention is variable from person to person and influenced by age and mental aptitude. From time to time, attention is also variable within an individual due to influences such as distractions, alcohol, drugs, and fatigue.
It is difficult to reduce the risk of inattentional blindness, as it is an involuntary and unnoticed consequence of our adaptive ability to defend against information overload. Error-reduction strategies such as education, training, and rules are of little value. Instead, efforts should center on increasing conspicuity of critical information, and decreasing diversions of attention and secondary tasks when carrying out complex tasks.
References: 1) Green M. “Inattentional blindness” and conspicuity. Visual Expert 2004 (www.visualexpert.com/Resources/inattentionalblindness.ht ml). 2) Angier N. Blind to change, even as it stares us in the face. The New York Times April 1, 2008 (www.nytimes.com/200 8/04/01/science/01angi.htm?_r=2&ex=1207713600&en=204&oref=slogin). 3) Federal Aviation Administration (FAA). FAA human factors awareness course. (www.hf.faa.gov/webtraining/Intro/Intro1.htm). 4) Arons B. A review of the cocktail party effect. MIT Media Lab; 1992. (www.media.mit.edu/speech/paper s/1992/arons_AVIOSJ92_cocktail_party_effect.pdf).
Monday, March 9, 2009
Updates and Spine Program
It's time to update this Blog!
A warm welcome to Prema Arulanantham who survived the George Brown Critical Care course and is now finished her orientation to PACU. Stacey Lauzon is currently in the GBC Critical Care Course, and we wish her continued success as she starts Phase 2 of the program.
Farewell to Betty Manino who remains within the PeriAnesthesia environmentand in the Endoscopy Clinic, and Nadiya Arkhipova who has returned to the TECC program.
The Surgical Short Stay Unit continues to expand! They are now up to 8 beds and patients now also include Spinal patients who stay for one night in the SSSU and are transfered to the Holland Centre in the morning.
For more information on the Spine Program, click HERE!
A warm welcome to Prema Arulanantham who survived the George Brown Critical Care course and is now finished her orientation to PACU. Stacey Lauzon is currently in the GBC Critical Care Course, and we wish her continued success as she starts Phase 2 of the program.
Farewell to Betty Manino who remains within the PeriAnesthesia environmentand in the Endoscopy Clinic, and Nadiya Arkhipova who has returned to the TECC program.
The Surgical Short Stay Unit continues to expand! They are now up to 8 beds and patients now also include Spinal patients who stay for one night in the SSSU and are transfered to the Holland Centre in the morning.
For more information on the Spine Program, click HERE!
Friday, January 23, 2009
SDS Hand Hygiene Compliance rates
Late last year a hand hygiene audit was done in the SDS by a Master's student in Epidemiology. Her study included Pre-and Post InService data.
Here are the results. Good Job!!!
Hand hygiene compliance rates among RNs
HH performed HH opportunities HH compliance 1st moment 3 52 6% 2nd moment 1 34 3% 3rd moment 8 21 38% 4th moment 19 63 30% Overall compliance 31 170 18% Post intervention - hand hygiene compliance rates among RNs HH performed HH opportunities HH compliance 1st moment 25 63 40% 2nd moment 10 27 37% 3rd moment 16 24 67% 4th moment 33 62 53% Overall compliance 84 176 48% Hand hygiene compliance rates among Anesthesiologists HH performed HH opportunities HH compliance 1st moment 2 7 29% 2nd moment 4 18 22% 3rd moment 2 2 100% 4th moment 2 10 20% Overall compliance 10 37 27% Post intervention hand hygiene compliance rates among Anesthesiologists HH performed HH opportunities HH compliance 1st moment 4 9 44% 2nd moment 1 8 13% 3rd moment 2 2 100% 4th moment 2 10 20% Overall compliance 9 29 31% The Day Surgery Unit demonstrated an overall HH compliance rate of 19% (220/41). By HCW, the HH compliance rate among the nurses was 18% (170/31) with the lowest compliance during the 1st and 2nd moment at 6% (52/3) and 3% (34/1), respectively. Among the anesthesiologists, the compliance rate was 27% (37/10), with lowest compliance during the 4th moment at 20% (10/2). Post intervention, the compliance rate, among nurses, increased substantially. Within this group, HH compliance increased from 18% (170/31) to 48% (176/84). This increase in compliance was significant (p<0.001). With regards to the anesthesiologists, with whom the intervention was not performed, results indicated that HH compliance went from 27% (37/10) to 31% (29/9). This was shown to not be significant (p=0.768). *** Please note that the intervention was only carried out with the nurses.
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