What a difference a day makes!
I have worked the last four nights in a row. Friday - Busy, we were short on staffing. Saturday - Busy, full staffing, but a MCI in which we received 7 Level I Traumas within 45 minutes. Sunday - Umm, full staffing, department almost empty of patients (average of 20 out of 60+ beds occupied), staff sent home and beds blocked. Monday - Couldn't tell you, my last shift of four in a row, bring it on... you can't hurt me, I'm about to be off for four days!
However, don't think I wasn't "in the game" or "on point"...
Last night, I was assigned to a psuedo-extension of the ED, the 'Clinical Decision Unit.' This Unit is where a patient goes when they are too sick to go home, yet not sick enough stay in the ED or to be admitted to the hospital. Think of it as an 'Overnight(s) Stay Unit.' It's a weird mix of floor nursing and ED nursing combined together.
As I was doing the nightly chart check, which is like an audit of everything that has occurred in the past 24 hours, I came across, shall I say, a discrepancy between what is actually a 'bizarre' physician order, how it was interpreted, and ultimately, how it was being implemented. So, I looked back and did a 48 hour chart check - found the same issue. Then a 72 hour chart check and ultimately was able to figure out where the problem arose.
Once I identified the problem, I called the on-call physician to explain the issue, how it has had an effect on care delivered so far, and what I thought would be the appropriate course of corrective action from a nursing perspective. Through collaboration, we changed/clarified the order and corrected the course of treatment. The patient will be hopefully be discharged later today, as opposed to an additional 2 or 3 days of a hospital stay.
In a "non-emergency" way, I saved a patient from further suffering and quite possibly their life, as this misinterpretation had some mid to long-term consequences had it not been identified and corrected. I fully admit, I was the fourth nurse to misinterpret the initial order. It wasn't until 2/3 of the way through my shift, when I was critically conducting the chart check, that the "proverbial" red flag went up!
Medical providers are not infallible. We are all humans and therefore, prone to make mistakes. Two physicians, at least one pharmacist, and four nurses (myself included), all let this issue pass by on our radar screens... I was just the lucky one to decide to pay attention to that little blip that I saw later out of the corner of my eye. All the 'holes in the Swiss-cheese' had lined up and allowed this to fall through. This was, in a Root Cause Analysis, a combination of a Systems Problem and Pure Human Error.
Unfortunately, in my opinion, this would have been averted from the get go, if the old fashioned KARDEX System had been used, even as much as I hated using it. With government mandated CPOE (Computerized Physician Order Entry), EMR/EHR (Electronic Medical/Health Records), and the integration of the two... things now occur automatically between systems based on rules. There is very little 'human interaction' at times.
Obviously, I do not agree that computerization/automation of processes 'always' improves efficiency. It took a human, to critically review, to identify a problem in an automated system. If that is what it takes to prevent mistakes, then I say scrap the automation created to prevent human error! It was a human that prevented an ongoing error 'allowed' by an automated system!
I humbly step-down from my soap-box.
