Patient Safety / ER Case

[watto]

Hi everyone - I'm an MSI working on a patient safety case that hinges upon an ER encounter early in a patient's (eventually fatal) hospital experience.

Does anyone know what the protocol is for the passing of information? Specifically, the patient in this case had an order for heparin put in by the ER doctor on duty, but it wasn't filled until four hours later. She had been admitted during that time period but the management of her medication slipped through the cracks. The hospitalist in the neuro ward where the patient wound up also put in a heparin order that was not immediately filled, but I am more interested in the mechanism by which someone is moved out of the ER.

Are you familiar with any hospital policies that ensure ER orders are filled before patient transfer, or is the process highly variable?

Thanks for the information - I'll take whatever I can get!

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[anonymousEM]

depends...nurse taking care of the patient should've called report to the floor where the pt was going next...including any orders yet to be done. When a nurse completes an order, it's timed and initialled most places...these procedures can vary by institution.

Good luck using this board to get your info...I wish I would've thought of that for some of my MS I cases...I spent a lot of time trying to look up things that would've been simple for someone with more experience.

 

[Annette]

I think it varies place to place. In the places I have done rotations, I've had the order ok'd, then submitted in writing (or on the computer) and then told the nurse taking care of the patient. Theoretically, I didn't have to tell the nurse, but I was told that letting the nurse know that there is an order helps to get it done faster. (Just common sense and politeness- the nurses can be more harried than the docs.). As far as how the nurses handle it from there, I don't have the foggiest. If the order hadn't been taken care of in what I considered a reasonable time, I'd (VERY POLITELY) ask the nurse about it.

The doc is more responsible for making certain the orders are carried out than the nurses. The patient is the doctor's responsibility. It doesnt' play well in a court room to say that the nurse was at fault.

 

[edfig99]

order pickup is very variable, especially in an ER depending on the acuity of the other cases in the ER.

What should ideally happen in the case of a true emergency, where it is imperative that a medication be given fairly quickly, the order should be entered, and the doctor should speak to the nurse and inform her that this is an urgent ("stat") order. 9 times out of ten the nurse will get to that order in less than 15 minutes (of course depending on what other stuff she is working on at that time) The physician should check periodically (maybe 15-30 min) to see whether or not the medication has been initiated. If not, then he can either speak to the nurse again, or, if he knows what's where...can intiate the administration of the medication and sign off on the order. HOWEVER this can be associated with it's own set of problems, as really doctors and nurses have different skills, and nurses generally are more in tune with hospital policies, particularly as it pertains to medication administration.

if a patient is about to be transferred out of the ER to the floor, the ER nurse MUSt call/fax the floor nurse to give report. At that time they should review the er course briefly including orders. At our institution, I have seen a nurse say, "oh he just wrote for xyz...i'll give it to her now" and I have seen "oh, he just wrote for xyz, i did not give it, so the patient needs it on arrival to the floor..." at that point the patient is transferred and if it's a good nurse, that patient will get the missing er med upstairs on the ward.

on arrival to the floor, however, the priority is generally not to give missing meds (except in the ICUs) -- instead it's to begin to fill out the inordinate amount of paperwork that counts as a nurse's admission note. Because of an overwhelming amount of regulation, sheets and sheets of paper outlining various oversight agency-required checkboxes are addressed before the patient can get anything....then if the Er order is written incorrectly, the nurse would have to page the accepting doctor and wait for them to come and write admission orders and all that jazz....

it's very easy for 15 minutes to turn into 4 hours...and unfortunately, bad things can happen...

 

[watto]

Thanks for culling from your experience to share this information with me. It is extremely helpful.

It seems to me that the major holdup in the system is in all that administrative paperwork that becomes the priority when a patient is admitted. While it always makes sense to streamline that as much as possible, in this case I think it's the de-prioritization of the initial orders that is the problem.

Also, I have found (from discussions with others in the ER) that there is a lot of uncertainty over who is, finally, accountable for the patient re: meds. It does make sense that the doctor should play this role, however some hospitals are hiring nurse managers to deal with the delivery part of care. Like they might be ultimately responsible for communicating to the patient's nurse that an order has not yet been filled yet and requesting that it be taken care of. This eliminates the need of the physician to monitor status of service past a certain point and gives the role to someone with special training dedicated to operational issues.

Anyway, thanks everyone, your comments were great.

 

[ERMudPhud]

Our nurses read through the ER orders and meds given during their report to the upstairs nurse so that anything missed can be given upstairs. That being said, if it is a med I really care about I usually ask the nurse at some point,"have you given the aspirin(or other med) yet to Mr. Smith?"