War against the nursing staff.

[Sparda29]

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Is this war winnable as a pharmacist? So many things at this hospital that have got to change. ****ing nurses coming running over from the ER for meds that don't even need to be administered immediately. Then the nurses from the CCU and ICU who think that their stuff takes priority over the rest of the hospital.

What the **** is it with nurses and specific dose times? I'm here for the 3PM-11PM shift. From 5PM-7PM, it is an absolutely nut house, and then it calms down, and then boom at 930PM it is a nuthouse again until I leave at 11PM. Is it that big a deal that a patient doesn't get a med at 6PM or 10PM and gets it at 8PM or 12AM instead?

 

[Nymphicus]

Charts, charts, charts!

 

[Sparda29]

Charts, charts, charts!

Good god, I forgot, the nurses who come running over for STAT meds, but don't bring the ****ing order with them.

"But, but it's only silver sulfadiazine, Do you want their arm to burn off by sending me back to get this paper?"

 

[Its Z]

You know how I know you work for a piss poor managed hospital?

Nurses are running around trying to get meds.

Pharmacy will never win the war against nursing.

Better yet, it's not a war. Pharmacy is an ancillary service, not the center of the universe.

Nursing is the core business in patient care.

Take care of nursing and your life will get easier.

 

[Sparda29]

You know how I know you work for a piss poor managed hospital?

Nurses are running around trying to get meds.

Pharmacy will never win the war against nursing.

Better yet, it's not a war. Pharmacy is an ancillary service, not the center of the universe.

Nursing is the core business in patient care.

Take care of nursing and your life will get easier.

Hospital was losing massive amounts of money every year. We actually still lose about $20 million a year but since we are part of the largest hospital network in the NYC metro area, it doesn't really matter. Apparently we are a "feeder" hospital.

We have runners but I'm not gonna send them up for every little thing since I like to use them as pharmacy tech-assistants. Only place with a Pyxis is the ER and the nurses HATE using it. We encourage them to go to Pyxis, yet they still come back to the pharmacy, oh it's not working, drawer needs to be recovered, etc.

We don't have a pneumatic delivery system. Probably too late to install one.

Take care of nursing as in what, delivering meds on time to every one? Not gonna happen, definitely not with just 2 pharmacists, one tech, and a runner. I think in today's shift alone, I probably processed over 300 orders, and when I left, the fax machine had about 150 pages of paper worth of incomplete orders.

What I hate the most is how apparently it is the pharmacy's responsibility when meds are forgotten during a patient transfer from the ER to the floor, floor to ICU/CCU, ICU/CCU to floor, and whatnot. Just today I got into a fight with a CCU nurse about this. I was about to leave, nurse calls down, I actually pick up the phone (shouldn't have done that), and then the nurse starts bitching about how all the meds are not there. I tell her to go look in the medication room in the last floor the patient was on or have the nurses from that floor bring it to you and hang up. She calls back yelling saying that it's not her job to go looking for missing meds, blah, blah, blah, I can't leave 2 critically ill patients to go on a wild goose chase for meds, etc.

 

[Its Z]

And yes, critical care meds are often very "critical." And no, critical care nurses should not leave the unit to come pick up meds. Everyone is busy...and everyone is on the same team.

 

[Its Z]

and you know how I just confirmed your hospital sucks?

Pyxis in ED only...and still use fax???

LOL.

 

[Its Z]

It is the responsibility of the Pharmacy department to have the right medication available to the right patient at the right time. It is the most basic responsibility that has to be met. If not, then your dept has failed.

 

[Sparda29]

And yes, critical care meds are often very "critical." And no, critical care nurses should not leave the unit to come pick up meds. Everyone is busy...and everyone is on the same team.

Alright, I get it with the vasopressors and whatnot. No one is gonna die if they take Cipro at 11PM instead of the scheduled 10PM.

Everyone is busy, but apparently nursing staff doesn't understand that. Apparently, their time takes priority over our time. We pick up the phones within 3 seconds, and god forbid I call them during shift change, I get yelled at for interrupting the "nurse report".

 

[Sparda29]

and you know how I just confirmed your hospital sucks?

Pyxis in ED only...and still use fax???

LOL.

I cannot wait till January. EMR and CPOE baby! And the plan with this is to have pharmacists out on the floor verifying meds and maybe even dispensing from the floor with our medication carts. Now, one thing I do dislike about this hospital is how it's not a teaching hospital. All the physicians are veteran, battle-tested, in the field for 15+ years. No hospitalists except for ICU and CCU, and no medical residents.

It is the responsibility of the Pharmacy department to have the right medication available to the right patient at the right time. It is the most basic responsibility that has to be met. If not, then your dept has failed.

Yeah, but why should I have to do extra work when they can't find the med? Lately, I've been deliberately holding meds until the scheduled dose time because of this. Coumadin is one of the drugs they dose 10PM here. If I send any up from 3PM-9PM, almost guaranteed, I will get a call around 945PM saying they can't find the one pill that I sent up.

 

[Its Z]

Alright, I get it with the vasopressors and whatnot. No one is gonna die if they take Cipro at 11PM instead of the scheduled 10PM.

Everyone is busy, but apparently nursing staff doesn't understand that. Apparently, their time takes priority over our time. We pick up the phones within 3 seconds, and god forbid I call them during shift change, I get yelled at for interrupting the "nurse report".

If a medication is due at 11pm, then most likely you have a medication management policy that states the medication must be given with in 1 hour of due time, 30 min before or after. That was a CMS mandate until last year and most facilities have not made a change.

And it's your job to have the medication available to them at 11... not their job to go around and find it. And when they're in a shift change report, you shouldn't expect a prompt response unless it's an emergency.

You probably think I'm siding with nursing but I'm not. Im siding with quality patient care.

Your job is to provide quality patient care.

The best way to do that is help make Nurse's job easier by having the right meds at the right time for the right patient.

 

[Its Z]

I cannot wait till January. EMR and CPOE baby! And the plan with this is to have pharmacists out on the floor verifying meds and maybe even dispensing from the floor with our medication carts. Now, one thing I do dislike about this hospital is how it's not a teaching hospital. All the physicians are veteran, battle-tested, in the field for 15+ years. No hospitalists except for ICU and CCU, and no medical residents.



Yeah, but why should I have to do extra work when they can't find the med? Lately, I've been deliberately holding meds until the scheduled dose time because of this. Coumadin is one of the drugs they dose 10PM here. If I send any up from 3PM-9PM, almost guaranteed, I will get a call around 945PM saying they can't find the one pill that I sent up.

The reason your coumadin went missing is because another nurse probably needed it for another patient and stole it. It boils down to system error in your medication process.

Y'all have a bad managment.

 

[rxlea]

Sounds like a cluster ****. These are all things that could be rectified with good management and collaboration between departments, with an emphasis on patient care. It's an education thing in addition to maintaining workflow consistency, establishing guidelines, standardizing medication requests, and ensuring accountability where needed. Ths whole nursing vs pharmacy mentality is a disservice to patients. There shouldn't be a war. There should be a discussion of solutions. The Pyxis only in ED is absolutely bizarre to me but I'm going to assume it's cost related...although if you add up all the cost with duplication in orders, lost meds, time spent faxing and calling and running around, it would far exceed the cost to have a Pyxis on the floor that is refilled on a regular schedule with fast moving medications. Do you have batch fills at least? Timing them appropriately would help. What about patient specific bins? Does your runner go up on a regular schedule? Can you show nurses how to recover a drawer? Is the Pyxis refilled regularly? What's in it? You can put antibiotics in there so things like cipro, vanco, azithromycin, ceftriaxone, can e be started in the ED.


Sending up a dose at a time and nurses having to request it every single time is ridonk. Your process sucks. You should help in fixing it instead of bitching.

PS CPOE won't fix everything. If you have a crappy system now without teamwork, what makes you think it won't be that way EMR or not?

 

[confettiflyer]

I cannot wait till January. EMR and CPOE baby!

heh heh heh...oh i can't wait to see the posts from you in january

 

[confettiflyer]

Dude, is this your first time working in a hospital or something? You sound like me as a P1.

 

[confettiflyer]

****ing nurses coming running over from the ER for meds that don't even need to be administered immediately.

Nurses shouldn't leave their unit...ever.

Then the nurses from the CCU and ICU who think that their stuff takes priority over the rest of the hospital.

Because it does.

 

[confettiflyer]

I get yelled at for interrupting the "nurse report".

Yeah don't do that. Even I don't do that... and I'm an assho1e.

 

[rxlea]

heh heh heh...oh i can't wait to see the posts from you in january

Right?

Our transition was rough. We're currently implementing Talyst and people are not happy...that is an understatement.

With that said, I've learned that every major change (I've been through several) requires patience, proper training, support from management, and the constant reminder that it's about patient safety and quality care.

People hate change but it happens regardless. The task is to make the best of it, improve the process so it's optimal for your institution, and promote teamwork. The latter involves taking input from ALL members of the team.

 

[rxlea]

If you time the batch fills to print only 3 hours before delivery, the new room numbers would come up. You can print a transfer report before the batch delivery is made/delivered. Having a Pyxis in the ICU and medsurge negates the need to transfer **** like coumadin with the patient, as you can set up the Pyxis to print report every hour with new orders with meds not loaded in Pyxis, with the dosing interval. The runner can then load the new med in Pyxis when they go up to deliver with the appropriate amount of meds... 20 doses for BID, for example. You can load fluids, advantage vials, famotidine, benadryl, ASA, APAP, morphine, coumadin, etcetc. Hell, throw flu vaccines in a locked drawer in the fridge with the key in Pyxis. Get nursing management on board to train nursing staff. Do regularly timed runs for new orders and train nurses to know when it will come up. Just a few suggestions off the top of my head.

Your welcome for your free consult. K bye.

 

[Sparda29]

Sounds like a cluster ****. These are all things that could be rectified with good management and collaboration between departments, with an emphasis on patient care. It's an education thing in addition to maintaining workflow consistency, establishing guidelines, standardizing medication requests, and ensuring accountability where needed. Ths whole nursing vs pharmacy mentality is a disservice to patients. There shouldn't be a war. There should be a discussion of solutions. The Pyxis only in ED is absolutely bizarre to me but I'm going to assume it's cost related...although if you add up all the cost with duplication in orders, lost meds, time spent faxing and calling and running around, it would far exceed the cost to have a Pyxis on the floor that is refilled on a regular schedule with fast moving medications. Do you have batch fills at least? Timing them appropriately would help. What about patient specific bins? Does your runner go up on a regular schedule? Can you show nurses how to recover a drawer? Is the Pyxis refilled regularly? What's in it? You can put antibiotics in there so things like cipro, vanco, azithromycin, ceftriaxone, can e be started in the ED.


Sending up a dose at a time and nurses having to request it every single time is ridonk. Your process sucks. You should help in fixing it instead of bitching.

PS CPOE won't fix everything. If you have a crappy system now without teamwork, what makes you think it won't be that way EMR or not?

Batch fills are done during the day shift, and it is like a good day supply of IVs. Now, something that I think should be changed is that, my one pharmacy technician should not have to do anything except for helping me fill and answering the phones. **** refilling the code carts, Pyxis, and restocking the back room. That should be done by the day shift. When I arrived this afternoon, there were about 200 unfilled orders in the fax. It doesn't help that me and the other 3PM-11PM pharmacist are both new hires. She's been a pharmacist for a few years but she only had retail experience.

Dude, is this your first time working in a hospital or something? You sound like me as a P1.

First time working in acute care. Other than rotations, the only institutional experience I've had was at a sub-acute rehab/nursing home. It was much different there, we had much more power.

Nurses shouldn't leave their unit...ever.



Because it does.

I agree, I don't want them to leave their unit to come downstairs to slow us down. In fact, I don't want them to call me looking for stuff either. Why don't they realize that their calling down and coming down only delays everything?

 

[rxlea]

Batch fills are done during the day shift. Now, something that I think should be changed is that, my one pharmacy technician should not have to do anything except for helping me fill and answering the phones. **** refilling the code carts, Pyxis, and restocking the back room. That should be done by the day shift.



First time working in acute care. Other than rotations, the only institutional experience I've had was at a sub-acute rehab/nursing home. It was much different there, we had much more power.



I agree, I don't want them to leave their unit to come downstairs to slow us down. In fact, I don't want them to call me looking for stuff either. Why don't they realize that their calling down and coming down only delays everything?

Every shift is responsible for maintaining med stock in the hospital. Do you know how many phone calls would be eliminated if nurses can find their meds? That frees up time to do other stuff! Time is money. Especially in a hospital.

 

[Sparda29]

Every shift is responsible for maintaining med stock in the hospital. Do you know how many phone calls would be eliminated if nurses can find their meds? That frees up time to do other stuff! Time is money. Especially in a hospital.

We have nurses who call us before they even look in their medication room, or the patient carts, or the fridge.

 

[rxlea]

We have nurses who call us before they even look in their medication room, or the patient carts, or the fridge.

Right. This is where education and consistency come in. meds up there before the dose is due, nurses being trained to look at three places, when they are on the phone make them look. meds go in patient bin unless refrigerated. Same location EVERY TIME. Regular runs and they'll eventually learn. Change takes time but eventually you'll be a well oiled machine. Trust me. bitching and warring and getting pissed gets you nowhere.

Look, we've had the same problem. I've seen it other places and did a QI project at one. It's workable/fixable with the right leadership and mindset.

 

[Sparda29]

Right. This is where education and consistency come in. meds up there before the dose is due, nurses being trained to look at three places, when they are on the phone make them look. meds go in patient bin unless refrigerated. Same location EVERY TIME. Regular runs and they'll eventually learn. Change takes time but eventually you'll be a well oiled machine. Trust me. bitching and warring and getting pissed gets you nowhere.

Look, we've had the same problem. I've seen it other places and did a QI project at one. It's workable/fixable with the right leadership and mindset.

That's the other thing. How should I know when a dose is due? It doesn't say on the physician order form.

Something else I've noticed is that, in the pharmacy department, once your shift is over you leave regardless of if your work is complete or not.

I have nurses who call me and say that they wanna go home at 11PM but then say they can't go home until they administer the meds. Why can't they pass it on to the next shift?

 

[rxlea]

That's the other thing. How should I know when a dose is due? It doesn't say on the physician order form.

Something else I've noticed is that, in the pharmacy department, once your shift is over you leave regardless of if your work is complete or not.

I have nurses who call me and say that they wanna go home at 11PM but then say they can't go home until they administer the meds. Why can't they pass it on to the next shift?

You should have regular administration times. This is standard practice. 0900 1300 2100 for example. Things like antibiotics, especially. Unless they are new starts. Give "now" dose Then time them for next administration time if possible.

I don't know what your nursing policy is, but if they are giving 2100 meds, 2300 doesn't seem far fetched and you're not pressed.

 

[Sparda29]

Another thing that would help is if pharmacists had the power to fix incorrectly entered orders. Doctor orders Gentamicin 100 mg in 100 ml D5W, we dispense in 100 ml NS, this is something that I should not have to call anyone for, or fill out any forms for. Or an order for 16 mg Norepinephrine in 500 mg D5W, we dispense in 250 ml bags, I should be able to make that switch to 8 mg/250 without authorization.

I would save so much ****ing time if I didn't have to track down the doctors. I had one doctor go all sarcastic on me when I called him to inform him of a steroid allergy when he ordered Lotrisone cream. "Have you ever heard of an allergy to steroids?"

 

[rxlea]

Another thing that would help is if pharmacists had the power to fix incorrectly entered orders. Doctor orders Gentamicin 100 mg in 100 ml D5W, we dispense in 100 ml D5W, this is something that I should not have to call anyone for, or fill out any forms for. Or an order for 16 mg Norepinephrine in 500 mg D5W, we dispense in 250 ml bags, I should be able to make that switch to 8 mg/250 without authorization.

That is a pharmacy practice issue and protocol issue management should have the leadership to address with the appropriate team/committee.

You can write protocols for what can be changed.

E DIT:: with cpoe, selection s will be built so physicians can only choose standards unless there is some other reason like fluid restriction.

 

[Sparda29]

That is a pharmacy practice issue and protocol issue management should have the leadership to address with the appropriate team/committee.

You can write protocols for what can be changed.

E DIT:: with cpoe, selection s will be built so physicians can only choose standards unless there is some other reason like fluid restriction.

I know, that's one good thing about it.

 

[rxlea]

Dude you have so many problems that you need a pharmacy practice team and a QI consult. Hell give me just a couple months at your joint and I'll give you results...for a price it sounds like tackling even one or two of your problems would alleviate so much.

 

[rxlea]

CPOE needs to come first. Then the tweaks/changes. I hope you have an IT informatics team.

 

[Sparda29]

CPOE needs to come first. Then the tweaks/changes. I hope you have an IT informatics team.

I'd hope so since the entire health system is doing this upgrade.

 

[PharMed2016]

It doesn't help that me and the other 3PM-11PM pharmacist are both new hires. She's been a pharmacist for a few years but she only had retail experience.

Hmm, I thought that it's nearly impossible to go retail-hospital especially given the current climate.

 

[mustang sally]

Life is always sweeter if you get along with the nurses!

I hope things do get better for you in January, but from what I've seen introducing new technology is a giant learning curve that involves a lot of bumps in the road. Apparently the hospital I'm at now switched to Omnicell and CPOE a year ago and people still constantly call the pharmacy with issues.

 

[rxlea]

I'd hope so since the entire health system is doing this upgrade.

I mean pharmacy IT team.

 

[All4MyDaughter]

I all see in this discussion is how this affects Sparda and how things the nurses do annoy him and how he wants things to be for himself and his convenience. Not how things affect patient care.

I'll just leave these here:

 

[rxlea]

I all see in this discussion is how this affects Sparda and how things the nurses do annoy him and how he wants things to be for himself and his convenience. Not how things affect patient care.

I'll just leave these here:

Holy crap. It's only 7am!

Then again it IS election day. Drink either way...to drown sorrows or to celebrate another 4 years of sanity.

 

[Lubeckd]

That's the other thing. How should I know when a dose is due? It doesn't say on the physician order form.

Something else I've noticed is that, in the pharmacy department, once your shift is over you leave regardless of if your work is complete or not.

I have nurses who call me and say that they wanna go home at 11PM but then say they can't go home until they administer the meds. Why can't they pass it on to the next shift?

so do you dislike hospital or retail more?

 

[ethyl]

So why not just tube it and be done with it? Make the nurses happy. I tube the dumbest of stat meds but it prevents them coming to my door or a time wasting second phone call.

 

[Sparda29]

so do you dislike hospital or retail more?

I still dislike retail more. At least in hospital the director agrees with you about the issues. Not to mention, we can write up the nursing staff if they become a pain. You can't write up ******* customers in retail.

We had a nurse come in from ER yesterday asking for 4 potassium riders (20 meq/100 ml). First time, she just came without an order. Then she came with an incomplete order. Finally after coming back with a correct order, she has the nerve to ask me why I was checking the lab reports on that patient.

So why not just tube it and be done with it? Make the nurses happy. I tube the dumbest of stat meds but it prevents them coming to my door or a time wasting second phone call.

We don't have a tube system here.

Life is always sweeter if you get along with the nurses!

I hope things do get better for you in January, but from what I've seen introducing new technology is a giant learning curve that involves a lot of bumps in the road. Apparently the hospital I'm at now switched to Omnicell and CPOE a year ago and people still constantly call the pharmacy with issues.

I get along with MOST of the nurses, especially the nursing managers. It's just some nurses who are frikking annoying. They look like they are on speed or crystal meth, all disheveled, constantly tapping the counter while they are waiting. And for some reason, the day shift nurses that I met while I was training were a lot nicer than the night shifters that I have to deal with on a regular basis. Not to mention, the day shifters are much hotter.

 

[gtpederson]

Even if you had a tube system, getting them to check that before the phone call is next to impossible.

 

[rxlea]

Even if you had a tube system, getting them to check that before the phone call is next to impossible.

Not really. Training and education....

 

[NasserGH]

I appreciate you, because you're seeking for your rights as a pharmacist, but I don't think the way of seeking is totally right.
You have to deal with your cases in professional ways, starting with "EDUCATING" them about your task as pharmacist in the pharmacy\satellite, also as pharmacist when it comes to the patients.

apparently they don't know your role well reckon on

Then she came with an incomplete order. Finally after coming back with a correct order, she has the nerve to ask me why I was checking the lab reports on that patient.

So you MUST teach and educate them, in simple and lovely way 😀 > Don't forget to document anything that you do, to show them your noteworthy and substantial role.

 

[PikminOC]

You know how I know you work for a piss poor managed hospital?

Nurses are running around trying to get meds.

Pharmacy will never win the war against nursing.

Better yet, it's not a war. Pharmacy is an ancillary service, not the center of the universe.

Nursing is the core business in patient care.

Take care of nursing and your life will get easier.

No one wins any wars against nursing as their sheer numbers and lobbies are so massive and coordinated.

 

[xiphoid2010]

Even if you had a tube system, getting them to check that before the phone call is next to impossible.

That and have them actually remember to send tubes back is impossible. Luckily our tube doesn't work, but at least we have an automated med cabinet in each unit.

But as irritating as lazy nurses can be, remember what the purpose of your work is, to take care of the patients. I work with the DON to stamp out the most egregious nursing practices, but until then make sure the patient doesn't suffer because you are mad.

 

[confettiflyer]

nurses are your customers...if your customers come bug you for things, there's probably a process problem. Take care of your customers. Pharmacy needs advocates/fans in nursing to justify expansion of services and budget.

 

[xiphoid2010]

nurses are your customers...if your customers come bug you for things, there's probably a process problem. Take care of your customers. Pharmacy needs advocates/fans in nursing to justify expansion of services and budget.

But also keep in mind that customers are NOT always right. We had nurses who repeatedly violate policy of safe practices. One nearly killed a patient by administering 10x the dose of insulin because she couldn't be bothered to have the dose verified by a second nurse. I discovered it during an ADE chart review, had a serious talk with the DON who agreed to do a peer review which voted to report that nurse to the board of nursing and have her privilege limited.

Remember your duty is to the best interest of the patient, not to the benefit of the nurses if it runs contrary to that goal.

 

[confettiflyer]

But also keep in mind that customers are NOT always right. We had nurses who repeatedly violate policy of safe practices. One nearly killed a patient by administering 10x the dose of insulin because she couldn't be bothered to have the dose verified by a second nurse. I discovered it during an ADE chart review, had a serious talk with the DON who agreed to do a peer review which voted to report that nurse to the board of nursing and have her privilege limited.

Remember your duty is to the best interest of the patient, not to the benefit of the nurses if it runs contrary to that goal.

of course, but i don't think we're discussing pt safety and deadly disregard for policy...that's a different story.

i just think students/new practitioners need to learn how to play nice in the sandbox...sometimes that means looking like you're bending over backwards for some nurses. Perception is important, so is process.

 

[xiphoid2010]

of course, but i don't think we're discussing pt safety and deadly disregard for policy...that's a different story.

i just think students/new practitioners need to learn how to play nice in the sandbox...sometimes that means looking like you're bending over backwards for some nurses. Perception is important, so is process.

What I'm saying is that keep the best interest of the patient in mind vs nursing issues.

There are plenty of times when nurses will be in the wrong, and comes to pharmacy to cover their tracks. In these cases, unless it would harm the patient, pharmacy should stand by the rules. For example, how many times have nurse called you to "re-time" meds because they were too lazy/forgot give it on time?

Nurse and pharmacy should help each other make the care of the patient better. Again, best interest of the patient, not just nurses would likes to do.

 

[smercer]

The best way to fix a problem is to create accountability. Make them send MAR discrepancy forms that are signed with a reason for the retime. Let them know said forms will be monitored.

A year ago I took the time to draw up a form that nurses had to fill out to request MAR reprints. My rationale for it was that it is a waste of time for pharmacy to field calls for reprints of a MAR, as it was already printed once, and to create some form of accountability for who was requesting MARs and why. Took some time working with management and nursing to get it approved. I'm doing this and I'm just a tech, though it was a great experience, as I never realized how much had to happen to add a form to the system.

 

[Sparda29]

of course, but i don't think we're discussing pt safety and deadly disregard for policy...that's a different story.

i just think students/new practitioners need to learn how to play nice in the sandbox...sometimes that means looking like you're bending over backwards for some nurses. Perception is important, so is process.

I'll play nice, but I'm not bending over backwards for anyone. My old place used to write up nurses for requesting medications when they are lost or misplaced. Only reason to call for more meds is if patient spits it out. If you drop it, tell me you dropped it.