Nursing staff may contribute to blockages in the feeding tube. Nurses are expected to flush the tube before and after each medication to remove any residual clumps of pills that could build up to create a blockage and not mix medications together. The medications may solidify into clumps and must be given one at a time. Staff should flush the tube every 4 to 6 hours, whenever tube feeding is stopped, and before and after each medication.

The inside of the tube is not that large, about as large as a pencil. It is easy for large fragments to get caught inside the tube and clog it up. It is not easy to unblock the tube. There is a certain amount of folklore about remedies to unclog the tube and one of them are harmful. For example, harmful ones may include colas or cranberry juice. Warm water or enzymes may unblock the tube. In the worst case, the tube would have to be removed and reinserted.

If a physician or nurse practitioner orders a new medication, it should be in a liquid form. The liquid form is least likely to cause any blockages. Some medications do not come in liquid form. The nursing staff may assume they can crush a pill. Unfortunately, sometimes the potency of the medication is altered if it is crushed. Pills that cannot be crushed are ones that are enteric-coated, time-release or sustained-released or capsules.

Some medications may not be inserted into a thin feeding tube that may go into the small intestine. This is a significant factor that limits therapy. A nurse may commit a medication error by using the tube for medications.

Another source of medication error is mixing incompatible medications. Sometimes there are interactions between medications. The incompatibility results in the patient not receiving the therapeutic benefit of the medication. Prescribers and pharmacists are expected to detect such incompatibilities.

Nurses are supposed to be educated to not add medications to the tube feeding solution. They may interact with the solution. Also, the goal is for the patient to receive the medication at one time, not over many hours. Also, there may be timing issues related to giving the medication when the tube feeding solution is running. Possibly the solution should be stopped for a certain amount of time before the medication is given.

While delivering food through a feeding tube may be life-sustaining, tube feeding carries risks of aspiration (inhalation of food into the lungs) and of medication errors. Some question the quality of life for patients with long term tube feeding. See this article for more on that topic.

Med League has nurses who review tube feeding related suits. Please contact us for details.

2. Screen cases: Careful scrutiny of the medical record can eliminate many potential suits and lead to early settlements of claims that have merit. Nursing documentation often paints a vivid picture for both the plaintiff and defense attorneys, with each side using the record to draw conclusions about the events of the case. Expert witnesses will rely on the charting to form opinions about adherence to or deviations from the standard of care. It is therefore essential that the attorney have an intimate understanding of the medical record and how nurses document.

3. Treatment and damages: Nursing documentation provides essential information that describes a patient’s injuries or health status, major problems, effectiveness of treatment, and cooperation or lack of compliance with treatment. When correlated with other parts of the medical record, nursing documentation usually provides a complete picture of the patient’s condition. Discrepancies, if any, between the nursing documentation and that of other healthcare providers, can be crucial in a particular case. Nurses notes pinpoint delays in care and improvement or worsening of symptoms. Timing may be a critical factor in delivery of care. Physicians rarely time their notes, nurses usually do.

4. Legibility: Nursing documentation is often the most legible part of the chart and contains information that must be considered when evaluating a personal injury, malpractice, or product liability case. Comments that patients make about their injuries or the details of a personal injury case are often recorded verbatim by nurses. For this reason the attorney should request a complete medical record in order to gather facts that bear on the patient’s injuries.

Examples of gold

• that prior back injury from another car accident the plaintiff did not describe to his attorney,
• the note written in the recovery room about the time the burn was first seen on the patient’s leg,
• the emergency room note that the patient had AOB (alcohol on breath),
• the nursing note that an anonymous caller reported the father of a child with suspected shaken baby injuries had a history of hitting his wife,
• the note in the records about a loving son: He stated “I’ll be honest with you, I wouldn’t care if today she fell and split her head open. Then she’d have to go to the hospital and they could take care of her so I can do the things that I have to deal with.” (Thanks to Tom Conlon Esq. for this note) and
• the medication administration record that showed the patient received Morphine before the drug screen was done.

Yes, these are all true examples. Don’t be surprised by information in the medical records that could harm your client. Can’t read or are too busy to read the nurses’ notes? Retaining Med League’s legal nurse consultants to do a medical record summary or chronology can uncover important information that affects your case.

This blog post is modified from Nursing Documentation, a chapter written by Pat Iyer and Sharon Koob, in the fourth edition of Nursing Malpractice. See our webstore for details.

John Smith manages NursingUniforms.net a one stop shop for all your medical and nursing scrubs requirements.

See www.avoidmedicalerrors.com for more information on avoiding medication errors.

John Smith manages NursingUniforms.net a one stop shop for all your medical and nursing scrubs requirements.

For more tips on avoiding medication errors, see www.avoidmedicalerrors.com

The government is pushing e-prescribing. This number will continue to grow based on the Centers for Medicare and Medicaid Services “voluntary” incentive program. Although it is voluntary now, the program forces physicians to adopt e-prescribing by transitioning from incentive payments to penalties on covered Medicare charges.

E-prescribing should get another boost as the Drug Enforcement Agency interim final regulations that took effect June 1, 2010, will allow for e-prescribing of controlled substances (typically narcotic pain-relievers) in the US. Pharmacies may not begin to receive these orders for another 6-18 months as the software vendors make the updates to computer systems that will allow prescribers to transmit the medication orders, intermediaries to process the prescriptions, and pharmacies to receive them. Furthermore, as the regulatory barriers to controlled substances become more streamlined patients may be more likely to receive prescriptions for them.

Benefits
E-prescribing can and will benefit quality of care. The following are just some of the ways.

Drawbacks
A new technology is not without its drawbacks. Some of the more notable issues with e-prescribing include

About the author: Dave Boblenz, PharmD, is a pharmacist with over 14 years experience. He operates www.pharmacytechniciancertification.com.

Comments
As is true with any prescription, whether handwritten on a prescription pad or sent electronically to the pharmacy. Errors may be made in the drug selection, dosage and route of administration. The physician, nurse practitioner or physician’s assistant may fail to provide education about side effects or provide sufficient details to provide an informed consent about the risks of the medications.

In one study, doctors agreed to be recorded during patient visits as they prescribed drugs new to those patients. Here is the percent of time the doctors gave people the following critical pieces of information:
Reason for taking the drug: 87%
Name of the drug: 74%
How often to take it: 68%
How much to take each time: 55%
Side effects: 35%
How long to keep taking the drug: 34%

In addition to errors in prescriptions covered by a previous blog post, http://krmno.th8.us consider errors in filling e-prescriptions. The pharmacist or technician may have pulled the wrong drug off the shelf or provided the wrong dose. While e-prescribing reduces errors, it does not eliminate them.

References
Use of E-Prescribing Grows Dramatically
Physician Quality Reporting Initiative
A Clinician’s Guide to Electronic Prescribing
Elizabeth Bewley, author of Killer Cure, Dog Ear Publishing, cites the study by Derjung, T., Heritage, J. Paterninti, D. et al, “Physician communication when prescribing new medications”, Archives of Internal Medicine 25 September 2006

medication errors

It is estimated that 3.4 billion prescriptions were filled in the United States in 2003, which averages to 11.7 prescriptions per citizen. The enormous quantity of medications distributed each year translates to an inevitable number of misprescriptions–prescriptions that are inappropriate for a particular ailment and may be downright dangerous for a patient to take. A 2004 study found that 1 in 12 doctor’s visits in the U.S. resulted in the patient receiving misprescribed medications.

When misprescribing and overprescribing occurs, the negative effects range from simply not solving the health issue in question to actually worsening the condition. An over-prescription of anti-depressants, for example, could have reverse effects on a patient with depression. Misprescribing drugs could mean that the prescribed drug would pose a health threat. Prescribers advise not to take medication when one is not ill; thus, the dangers of prescribing something that shouldn’t be prescribed are clear. There is also a vast amount of money that is wasted when misprescriptions occur, a devastating dilemma for those who pay for their own medications or have expensive copays.

Healthcare providers may misprescribe for a number of reasons. The drug industry is a driving factor behind this persistent issue. Advertisements provided by drug companies promote certain medications to the point where patients request them by name, often leading prescribers to tailor their prescriptions around the patient’s wants rather than medical necessity. Additionally, the dangers of mixing certain medications are not always widely publicized and discussed. Prescribers may not ask for adequate background information from their patients, a vital step in determining whether a patient should add a new medication to what they are currently taking. Furthermore, research has shown that some doctors–particularly those who are ACoAs (adult children of alcoholics)–feel the pressure to please their patients and will act according to their patients’ requests.

“With doctors stretched thin, some [...] think writing prescriptions is the easy way out,” states an article about the stress of the medical community over misprescribing pain medications and other pills. Healthcare providers oftentimes go straight into prescribing another medication when the “disease” for which it is being prescribed is in fact a side effect of a drug that the patient is already taking. The professional will prescribe a drug to “treat” what is actually an adverse reaction to another medication, which could have been more effectively solved by lowering the dosage of the initial medication or replacing it with another form of treatment.

Due to adverse reactions to misprescribed and overprescribed pills, half a million people are hospitalized each year. The medications they are misprescribed lead them to experience reactions that could have been avoided had the pills been properly prescribed or not prescribed in the first place. Mistakes happen even in the realm of medical science, but prescribers must take more careful measures before issuing their patients a prescription. By exerting greater care in the issuing of medications, misprescriptions can be avoided.

This guest post is contributed by Adrienne Hurst at AllTreatment.com, a rehab center directory and substance abuse information resource.

Comments: Attorneys and their experts who evaluate the liability and damages issues surrounding prescriptions should consider:

Careful analysis of the medical record, with the assistance of a legal nurse consultant, can make all of the difference in the outcome of a case involving misprescription.

Sources:

http://www.worstpills.org/public/page.cfm?op_id=3

http://www.e-tmf.org/downloads/Why_Physicians_Misprescribe.pdf

http://www.in-pharmatechnologist.com/Packaging/No-improvement-in-misprescribing-rates

http://sundaygazettemail.com/News/201101161143?page=2&build=cache

This new study reviewed 2,341 patients’ records from stays at 10 North Carolina hospitals from 2002 to 2007. The reviewers found that 25 harms per 100 admissions had occurred, and that 63% of these harms were preventable. Harms that were detected were a consequence of procedures (186), medications (162), nosocomial infections (87), other therapies (59), diagnostic evaluations (7), and falls (5), among other causes. The large majority of identified harms were classified as category E or temporary harm (144) or category F or an initial or prolonged hospitalization (163) harms. Of the identified preventable harms, 13 caused permanent harm (category G), 35 were life-threatening (category H), and 9 caused or contributed to a patient’s death (category I).

The authors concluded harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level.

What is holding us back from making patient care safer? The authors pinpoint these factors:
Despite substantial resource allocation and efforts to draw attention to the patient-safety epidemic on the part of government agencies, health care regulators, and private organizations, the penetration of evidence-based safety practices has been quite modest. For example, only 1.5% of hospitals in the United States have implemented a comprehensive system of electronic medical records, and only 9.1% have even basic electronic record keeping in place; only 17% have computerized provider order entry. Physicians-in-training and nurses alike routinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand washing is poor in many centers.

If North Carolina, which has aggressively pushed patient safety, has not improved in 6 years, what is going on in the rest of the country?

computerized medical records and medical errors

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages. The third is prevention of medical errors.

From Patricia Iyer and Sharon Koob, Nursing Documentation, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition

* the oncology patient who suffered from a large extravasation of a chemotherapeutic drug;
* the patient who fell off the operating room table because the nurse did not apply safety straps;
* the patient whose swollen leg was not reported to the physician on the day of discharge, and who died of a pulmonary embolism shortly after discharge
* the man who jumped through a window because the nurse did not recognize the need to start one to one supervision
* the surgical patient diagnosed with a retained sponge despite the “correct” sponge count;
* the nursing home patient scalded in a bathtub;
* the psychiatric patient who had a history of suicidal ideation and attempts, who was unmonitored, left the hospital, and hung himself in the nearby woods;
* the pediatric patient who went into respiratory distress and whose home care nurse asked his father to come home instead of following directions to call 911;
* the nursing home patient who fractured two hips after being dropped out of a hydraulic lift by a nursing assistant, who did not report the incident;
* the postoperative woman who experienced intra-abdominal hemorrhage and subsequent shock that went undetected by the Post Anesthesia Care Unit nurse.
* untold numbers of pressure sore cases

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips at www.medleague.com.