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Some constant inpatient meds are "foreign" to ED nurses
Prevent harmful drug errors
Editor's Note: This is a two-part series on medication safety for inpatients being held in the ED. This month, we give strategies to reduce errors with inpatient medications. Last month, we gave strategies to avoid missed dosages.
Increased patient acuity and volume put "boarded" patients at high risk for medication errors, warns Kathleen L. Wurgler, RN, BSN, an ED nurse at Maine Medical Center in Portland.
Boarding patients "can make an ED nurse very stressed," says Wurgler. "It is our culture to meet a patient, form a plan of care, implement the stat orders, make a disposition, and move on to the next one."
A boarded patient's medications may not be verified by pharmacy, adds Wurgler, because they are not ordered stat. "There may be poor communication between the admitting team and the ED nurse caring for the patient to discuss the plan of care," she adds.
Medications common to patients in the inpatient setting may be "foreign" to ED nurses, says David M. Solomon, RN, BSN, CEN, EMT-P, patient care coordinator in the ED at Catawba Valley Medical Center in Hickory, NC. "It is time-consuming to have to research a seldom-administered medication in the ED that would be simple for the medical/surgical nurse," he says.
Wurgler says boarded patients may need a patient-controlled analgesic for pain control, which is not usually available in the ED. "While we are very familiar with the side effects, the ED nurse would need to get the hospital policy, the machine that infuses with the tubing, and of course, the key from the nursing supervisor," says Wurgler.
If you've never given a certain medication, Solomon says to check drug references on any side effects to look for, and do double checks with another nurse.
Psychiatric medications, such as lithium and thorazine, are dosed by the pharmacy, says Solomon, as these medications are not kept in the ED's automated medication dispenser. Since these patients are typically not placed in rooms with monitors, vital signs have to be taken frequently, he adds, because of side effects such as hypotension, dizziness, nausea, and vomiting.
"Constant patient monitoring is essential for patient safety," says Solomon. "Luckily, most patients taking these medications in the ED are prescribed these medications regularly."
Solomon says it is particularly important to monitor patients for the first and second doses to know how they are going to react to them. "Observation for one hour is good practice," says Solomon. "Side effects will usually occur shortly after administration."
Because medications may be given over multiple shifts, good bedside reporting is "a must," says Solomon. "Include any adverse or expected reactions to medications," he advises. "Our standard here is to perform one-hour rounding on all patients. This includes some type of interaction with the patient by a staff member." (See clinical tip on obtaining information on last doses, below.)
For more information on medication safety of "boarded" ED patients, contact:
Obtain or verify last doses with patients
To decrease the potential for medication errors in boarded ED patients, Elaine Marshall, RN, BSN, MHA, an ED nurse at Rex Hospital, Raleigh, NC, says that ED nurses should obtain and/or verify the time of the patient's last dose.
"When patients are placed on a scheduled dose in the hospital, it is on 'hospital time,' not patient time," says Marshall. "When you ask the patient about their last dose, you will often find that they may have already taken a daily dose, or take it at a different time."
Confer with the pharmacist as to whether the current dose needs to be rescheduled or if it is within the allotted timeframe for a dose, advises Marshall. "Be familiar with the medication type that they are giving. Is it extended release or a standard release?" she says. "It is imperative that the last dose time is known, so the patient is not overdosed."