This is a great explanation of how the overload that occurs in a nurse’s job can result in distraction and medical errors.

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.

• Heparin is a blood thinner that when used in low doses is supposed to keep central lines open.
• Heparin is a high risk drug that can cause deaths or reactions such as heparin-induced thrombocytopenia.
• In a six month period, 20% of the central catheters developed blockages when the heparin flushing protocol was in effect.
• Costs associated with removing the blockage were high. In one year, the hospital spent $150,000 on Alteplase to declog blocked CVADs.
• Flushing with heparin does not prevent clots or fibrin from forming on the tip or outside of the catheter, thus blockages can still occur in the blood vessel.

The hospital embarked on a change in flushing to eliminate heparin and instead, flush with normal saline three times a day.

The results: Initially the number of blocked central lines went down to 11% but within 5 months, the trend reversed and the number of blockages increased. Within 10 months, 34% of the catheters were becoming blocked. The IV team concluded that “The flushing technique was the number one reason for the increase in occlusions.”

I found puzzling the conclusions of the clinical specialist who presented this study. She wrote, “As evidenced above, CVADs were flushed unnecessarily with heparin causing potential harm to the patient. This project increased patient safety while helping to decrease cost to the hospital. More education will be done with the staff to decrease cost and occlusions and increase safety to the patient.”

Unless I am missing something, it looks like the increased rate of occlusions resulted in increased cost to the hospital. How does a 34% blockage rate show an improvement over a 20% blockage rate? What caused the initial drop in the rate of blockages? Was it really the nurses who should bear the brunt for the poorer results, or the fact that heparin is actually more effective than normal saline for flushing catheters?

When I was in staff development, I quickly learned that there are two reasons why nurses don’t do what they are supposed to do. First, they lack the knowledge. The solution is to teach them. Second, they know how to do something, but there are no consequences for not doing the correct thing. The solution is a management and supervision plan. In the Heparin study, the author implies that the results were poorer because of the technique the nurses were using (or not). Does this mean the nurses were not following the protocol, even though it was recorded on the medication administration record with spots to sign off three times a day? The write up of this study does not provide enough (or any) explanation for the rise in occlusions. But charging ahead and asserting or implying that the nurses were the reason fails to take into account that saline may be an inadequate substitute for Heparin.

Patricia Iyer is president of Med League Support Services, Inc.

The survey team consists of two appraisers and the visit is usually three days in duration. The visit has a planned agenda, which can be revised by the surveyors without notice. The organization must be fully prepared from the physical appearance and cleanliness to the information posted on bulletin boards. The staff must be prepared and comfortable discussing the material submitted and addressing questions or concerns from the surveyors. The appraisers also request the assistance of a staff nurse during the tours and scheduled meetings. The material submitted will be challenged throughout the visit to validate the information provided and to verify the staff’s knowledge and comfort with the Magnet standards. All nursing shifts are invited to participate with the interviews, validating compliance with the standards around the clock.

After the survey, the healthcare organization is notified of its Magnet status; this award is good for four years. Thereafter, an annual report must be submitted to assure the Magnet status is being maintained regarding quality outcomes and nurse sensitive quality outcomes.

Maintaining the Magnet culture after a survey is a colossal job. The forces must be updated, data collection continued, benchmarking completed, and statistics collected regarding recruitment and retention, education, and advancement. The information is submitted in an annual report (in a set format) to the Magnet organization. The data is reviewed by accrediting staff and comments or concerns must be addressed by the organization. The Magnet designation can be jeopardized if there is a serious occurrence or significant change in the management of the organization, or in the outcomes collected regarding the nurse sensitive outcomes. Not all organizations are re-designated or provide sufficient evidence to support Magnet designation.

How do you know if a hospital has Magnet designation? Very likely this is prominently displayed on the hospital’s website. Facilities that achieve this are proud of the accomplishment – it is not easy. You can check on the Magnet status of a facility by going to this link and selecting your state: http://www.nursecredentialing.org/Magnet/FindaMagnetFacility.aspx

Do you have something to say about a hospital that is applying for Magnet designation, or one that is already accredited? Input from the patients, families, clients, staff, and public with who healthcare organizations interact is sought to assist Magnet program appraisers in the evaluation of organizations applying for Magnet designation.

ANCC evaluates the environment in which nursing is practiced as well as nursing’s compliance with standards promulgated by the American Nurses Association. The written documentation is available for public review at the healthcare organization. Its exact location is indicated in the public notice posted at entrances throughout the organization’s facility. Anyone who would like to participate in this evaluation process is encouraged to do so. Comments are confidential and may be made anonymously. The Magnet Recognition Program accepts comments at any time. Please call toll-free 1-866-588-3301.

Is care perfect at a Magnet hospital? In a word, no. Med League has assisted attorneys who handle medical malpractice cases involving care delivered in Magnet hospitals. But overall, the care is better in a Magnet hospital. If you have a choice of where to go, a Magnet hospital may be your best one.
Sources:
Modified from Judy Rottkamp, Inside the Healthcare Environment, in Iyer, P., Levin, B., Ashton, K. and Powell, V. (editors) Nursing Malpractice, Fourth edition, Lawyers and Judges Publishing Company, 2011

http://www.nursecredentialing.org/Magnet.aspx

The Magnet Hospital Recognition Program for Excellence in Nursing Service was established in 1990. This designation was approved by the American Nurses Association (ANA) under the American Nurses Credentialing Center. The number of applicants and organizations has grown since 1994 when the first Magnet award was given.

In 1998, the program was expanded to long-term care facilities. Also in 1998, ANCC established the Institute for Research, Education, and Consultation (IREC). The goal of this institute is to ensure that there are broad and balanced products and services offered. As growth continued in all of the ANCC certification programs, ANCC established an international division to expand to all settings in 1999. 1

Goals
The Magnet Recognition Program has the following goals:

* Identify excellence in the delivery of nursing services to patients, clients, or residents.
* Promote quality in an environment that supports professional practices.
* Provide a mechanism for the dissemination of “best practices” in nursing services. 2

Requirements
To receive Magnet status, an organization and the nursing services department must have

* a nursing management philosophy and practices of nursing services,
* an adherence to quality standards,
* a chief nursing officer (CNO) supporting professional practice and competence, and
* an awareness of cultural, ethical diversity of patients, families, and their providers.

A benefit of this designation is recognition in the community. In addition, the organization can have increased utilization, enhanced marketing strategies, and improved nursing recruitment. Stability in nursing care is provided with positive patient outcomes. Nursing autonomy, in which nurses problem solve and actively participate in decision making with positive outcomes for patients and peers, is evident throughout the organization in collaboration with the CNO.

D. Characteristics
A Magnet hospital may positively contribute to your health and having a successful stay in the hospital. Research projects by Linda Aiken, PhD, RN, FAAN indicate that Magnet awardees have similar characteristics:

* reduced Medicare patient mortality (death) and morbidity (illness) rates,
* reduced mortality rates associated with the care of patients with AIDS in the acute care setting,
* increased patient satisfaction,
* decreased likelihood of nurses being dissatisfied and burned out,
* reduced needle stick injury rate among nurses,
* improved patient care ratios, and
* powerful and influential CNOs.3

See Part 2 in two days.

Modified from Judy Rottkamp, Inside the Healthcare Environment, in Iyer, P., Levin, B., Ashton, K. and Powell, V. (editors) Nursing Malpractice, Fourth edition, Lawyers and Judges Publishing Company, 2011

1. Current American Nurses MAGNET Recognition Program Manual, (2008)
2. Id.
3. MAGNET Hospitals Revisited: Attraction and Retention of Professional Nurses, eds M. L. McLure and A. S. Hinshaw, American Nurses Association.

Accidents and injuries happen in health care in a moment. A patient decides to get out of bed without calling for a nurse, trips on her IV tubing and falls, fracturing a hip. Nurses’ aides use a mechanical lift to get a patient out of bed. The sling under the patient is frayed and in a second, rips and drops the patient to the floor, where he lands on his head. A distracted physician writes an order on the wrong chart. A transporter misjudges the speed of the stretcher he is pushing and takes a corner too fast. The momentum throws the patient off the stretcher. These are all real stories. I could go on for pages about the events that occur in moments. Maybe you could too.

When my mother went into the hospital for surgery, she was taken to the surgical holding area. A nurse walked in with a basket of intravenous supplies, and began to lay out her equipment. She said, “Mary, it is good to see you today.” My mother replied, “My name is not Mary. It is Gladys.” The shocked nurse said, “Your name is not Mary Wilson?” and quietly picked up her equipment and disappeared. The nurse did not take the moment to verify the identity of the patient.

Last year a physician examined an abscess under my arm. He then quickly left the room, and did not take the moment to wash his hands, despite a large red sign over the sink that said, “Wash hands”. Who knows where he carried my germs?

It only takes a moment for a patient to speak up, to ask questions, to request attention. One of my employees had a carpal tunnel surgery done. On her first postoperative office visit, the surgeon began to walk out of the room, not allowing her to ask her questions. She said, “Yo! I have questions. Come back.” He did. He closed the door, sat down, and answered her questions.

An incident that forever alters a patient’s life can take place in an instant. Hopefully safeguards are in place that serve as part of the safety net. The fact that they don’t work is one of the foundations of the medical malpractice legal system.

What case have you worked on that resulted from an error that took place in a moment? Share your comments.

How can the social media site harm patients? Bear with me.

First, consider the popularity of this site. Facebook was started by college students who wanted dates. It has grown to close to 700 million users. In one hour, 10,417,000 people log onto Facebook.

Second, many people who use Facebook develop an addiction to it. They can become so caught up in checking what their friends and family are doing that they cross the line into addictive behavior. They check Facebook before they get out of bed. When nursing Facebook addicts start checking their feed during working hours, patients can be harmed. Call lights are unanswered; patients are not monitored. I know of 3 nurses who were fired when a patient’s call light went unanswered. He died; the nurses were on Facebook instead of attending to his needs.

As a result of Facebook addiction, some hospitals have blocked staff from being able to access Facebook. Nurses are professionals, and yet many have succumbed to the temptation to visit Facebook during working hours.

Take home message: A delay in answered call lights, or a failure to monitor, may be related to the distraction of Facebook. I can’t think of any legitimate reason for nurses to access Facebook during working hours. Can you? Add a comment.

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.

I recall when my father was in ICU nearly 33 years ago, he thought the alarms represented fire trucks, and could not understand why there were so many fires in the blocks around the hospital.

Alarm fatigue can be deadly

But technology relies on humans to hear, interpret, and respond to alarms. Sometimes alarms are false alarms and do not signify anything. Sometimes alarms are annoying; the nurses turn them off. Sometimes the alarm is turned off because the patient is being taken off the equipment temporarily and the nurse forgets to turn it back on. Sometimes the nurse mis-programs a complicated piece of medical equipment. And sometimes the volume is turned down, or the nurse is at a point on the nursing unit where she cannot hear the alarm.

The Boston Globe provided a special report on this subject. It offers the perspectives of the healthcare providers and the manufacturers. When an investigation of a patient death associated with an alarm failure occurs, it is often not the equipment at fault, but the staff who did not respond to the alarm. Healthcare professionals and manufacturers are trying to create safety solutions, for example, by creating more technology, like signs in the hallways to warn staff of an alarm. For more information, read the report and watch the video.

Investigating a claim
1. The biomedical department is typically asked to look at a piece of equipment associated with an untoward outcome. The hospital may generate a report that details their findings. This may or may not be discoverable.
2. The manufacturer may be asked to examine the equipment, and they also generate a report.
3. The hospital will have discoverable policies on setting and checking alarms.
4. The medical record may incorporate flow sheets with boxes to check off that alarms were set.
5. Cardiac monitors that detect arrhythmias may spit out paper that is time stamped. These times should be compared with the medical record.
6. Nurse defendants and fact witnesses should be asked about the healthcare environment, the frequency of alarms, the responses, and the nursing practices associated with alarms.