My name is Beth Anderson. I'm a nurse, and I like to make websites. I'm also 
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16% of the US economy runs on scrawly, handwritten notes.
By Beth | March 13, 2008
From A Scanner Brightly:
“Health care currently consumes 16 out of every 100 dollars in the USA, but electronic health records are next to non-existent. The few that are in existence don’t talk to any of the others.
If we ran banking like that we’d be… oh wait a minute, we did run banking like that. About a million years ago. Well, thirty anyway.
16% of the US economy runs on scrawly, handwritten notes.“
I would like to expand this thought to computerized physician order entry systems and here’s why:
I made a mistake yesterday. I didn’t just miss one order. I missed A WHOLE PAGE OF ORDERS.
Why? Because the doctor wrote them on a separate page and stuffed them into the side pocket of the binder, rather than putting them in the proper place.
I looked through the chart five different times, looking for an order and I couldn’t find one. There was nothing but blank orderset sheets, and a blank order page. I wasn’t too surprised though. This kind of made sense to me because there was no fellow in the case, and usually the fellow writes the orders. In fact, if you ask an attending to write an order they kind of turn away in a huff and say “I don’t do that. Get the fellow to do it.” In this particular case, I just followed the basic (unofficial) protocol for this procedure (Vital signs Q 15 minutes x 4, then q30 minutes x2, then Chest X-ray after 2 hours, then page the physician after the CXR has been read.)
I did all of that and paged the Radiology attending. He never responded. So after about 20 minutes I paged the urology attending. He called me right away and asked, “What about the CBC?”
“I didn’t draw a CBC.”
“Well I ordered one hours ago.”
“I’m sorry but I didn’t see any orders in the chart.”
“Well I ordered it.”
“Okay, well I’ll check the chart again, and in the meantime I’ll draw the CBC.”
I went back to the chart and low and behold there was an entire page of orders, stuffed into the side pocket, where miscellaneous patient info usually goes.
Fortunately no one was harmed, although the patient did have to stay in the recovery room for an additional hour because I didn’t see the order.
This was my mistake and believe me, I owned up to it. I apologized to the patient for creating this delay and I apologized to the attending for missing his order, but I know that this mistake could have been avoided if the recovery room used a computerized ordering system.
So this brings me to reason #2 I am thinking about leaving nursing: Being a nurse in the hospital is essentially about carrying out orders. You can sugar coat it all you want, and talk about how there’s a big difference between nursing care and medical care, but in the end, physicians write orders, and nurses carry them out. (And by the way, my BSN program did their best to convince me that this is not the case, but after three years of working in the hospital, I’m pretty certain that this is the case.) And yet there is such a lack of standardization in the way that doctors write their orders, so it can be difficult to carry them out. Do the recovery room nurses care about this? The answer appears to be no. Whenever I ask the nurses about this situation their reply is this, “Oh we’ve been fighting this battle for years. Nothing ever changes.”
How do you get beyond that kind of apathy?
Topics: Blog |
March 13th, 2008 at 9:31 am
It’s refreshing to read such candidness. I work in sales for Mountain Medical Technologies, producers of CYRAMED an EHR system and of course sit opposite of you and your problems on the other side of the clinicians and try to drill home the benefits of electronic medical record systems. The reason I got to read your blog is because I signed up with google alerts so I receive all things related to EHR and I am astounded at the amount of resistance there still is towards shifting from paper to electronic systems. I am even more shocked with the amount of blogs press releases and other media articles that are being published every day about incidents like yours or shortcomings of our healthcare system as a direct result of the lack of IT in this industry. Everybody knows about this! These incidents are happening with such frequency accross all medical environments yet all involved are sitting on the sidelines waiting for something to happen. I find it ironic. Anyway, Keep telling your story it may just be what’s required to push for reform in our industry. Good stuff…
March 13th, 2008 at 12:31 pm
Dont quit! What would I read?
March 13th, 2008 at 2:14 pm
I feel your pain, Beth. I’ve even cartooned and blogged about the same issue. Take heart, in perhaps fewer than 30 years, this situation will be rectified.
http://www.revolutionhealth.com/pages/cartoon–triage-nurse
March 13th, 2008 at 7:09 pm
Yah I agree with you here, still i wouldn’t leave nsg. Why don’t you try another unit?
March 13th, 2008 at 9:51 pm
Ahem, how is it your fault when the dumbass MD put the orders in some random side pocket instead up in the section marked ‘PHYSICIAN ORDERS’
March 13th, 2008 at 9:54 pm
I love using a computer system. The orders are for the most part standardized. There are order sets in our computer system that the doctor can choose. So, they go and click “post-op abdominal surgery” and twenty orders magically appear. Then they just add/subtract/individualize the orders as needed.
It’s much nicer when all the orders are in the same place and look the same. Not to mention the fact that they’re typed so that you can easily read them!
March 14th, 2008 at 3:49 am
Please don’t leave! There must be a way to remain a nurse and be content. I have quit my full-time job and now work as a nurse consultant and per diem nurse at several sites.
Maybe we just need to create a new type of nurse who functions in a world of his or her own…..Hmmmm. A nurse without a doctor….that could be the start of something wonderful.
March 14th, 2008 at 7:12 am
@ERNursey: I know, I know. I may be taking on too much of the blame. But the frustrating thing is that the recovery room chart has no organization or categories, it’s just a random CF of papers shoved into a binder. So technically I’m expected to look at every single piece of paper until I get to the one that has the orders on it. It’s a mess.
March 14th, 2008 at 10:44 pm
i know that clearly looks like apathy, but it could also mean something else. i maybe apathetic about the issue, but i know i still want to take care of sick people most of the times. despite the challenges, specifically standardization of anything as simple as where to put in the orders, i stay, not because i am content in shrugging off the glaring issues, but because it is what i want to do. that’s just me though…
but if the system or lack thereof frustrates you to a point of disgust, i totally understand why you want to leave nursing.
March 15th, 2008 at 8:40 am
That’s ridiculous that you would take the blame for not finding the orders. If you had EMR/CPOE, you’re still counting on MD’s to use the system properly if they use it at all. If there’s a culture of “I do what I want and it’s all the RN’s fault” that’s a much deeper problem.
http://www.leanblog.org/2008/03/waste-of-handwritten-notes.html
March 15th, 2008 at 12:03 pm
I bailed from healthcare after 6 years and I couldn’t be happier Beth. I’m surprised, in hindsight, that I tolerated the incompetence as long as I did. I gather that you’re in PACU — if it’s rough there it is 2x worse on the floors/units.
You could try another hospital in your area; but I would just take inventory of your skills and jump to something else. The idea of the meaningfulness of caring for people is bollocks.
And if you think about it, people who say stuff like that are a) rationalizing (cognitive dissonance) and b) devaluing everyone else in the economy (all of us who don’t/no longer care for patients). Though like others have said, the good news is that the RN is one of the more flexible licenses around. You’ll find something (or decide that was just a bad day and stick with it). I just wanted you to know that some of us have left healthcare and are immeasurably happier.
March 15th, 2008 at 2:16 pm
Missing the sheet of doctor’s orders which were placed randomly in the chart is a system error.
Claiming that this was your error and yours alone does the health care facility a disservice.
I too work in PACU where we have a blend of computer-generated orders and handwritten orders. There are several ways the error that occurred could have been averted and it isn’t the nurse’s on-going anticipation of a physician having perhaps hand-written an order and leafing through the chart at regular intervals. Neither is it so that a computer-generated order would necessarily have been seen immediately unless someone is constantly checking the printer for new orders(hopefully there is a unit clerk who’s job it is to do this).
Think of ways to avoid this happening again. One would put the onus on the writer of the order to alert the nurse that an order has just been written and left in the chart. Technology has come far but it doesn’t replace person to person communication.
March 15th, 2008 at 3:27 pm
dan: if it is bollocks to say i find caring for people meaningful, then, i am wrong to conclude (from your own words) that you are the one devaluing me just because as you say, i am only “rationalizing”?
just curious…
March 15th, 2008 at 5:10 pm
Wow, Dan. Those are some strong words. I appreciate your candor and feedback, and I do think there is some grain of truth to what you are saying.
That being said, (ha, that’s right I said it!) saying that the “meaningfulness of caring for people is bollocks” is pretty harsh.
I shudder to think what kind of society we would live in if no one truly found caring for people to be meaningful. A Clockwork Orange comes to mind.
March 16th, 2008 at 8:07 pm
Don’t quit nursing! I found the only way to get things done right was to go back to school and get my NP and do them myself. I am ultimately responsible for my patients. I know that going back to school takes us away from bedside nursing, but it was either that or lose my mind over the incompetents that were blaming the nursing staff for their own mistakes. Don’t get me wrong, nurses make mistakes too!!
March 19th, 2008 at 8:51 pm
[...] there was Dan. [...]
March 20th, 2008 at 12:08 pm
Beth, even though I don’t agree with most of what Dan said, he did have a point — the RN is very flexible. Go back to why you decided to become a nurse to begin with and use that as a place to start. I don’t know where you live, but there are DNP programs that offer a BSN to DNP, or you could enter an NP master’s program. That way, you’d still be a nurse, but would be practicing patient care in a different setting. Another suggeestion, given your past background, would be to get into nursing informatics and help eliminate the problems you’ve encountered!
March 21st, 2008 at 7:31 am
Beth, First, I have to say good luck with your nursing career. Second, I have to say PLEASE DON’T QUIT! At least don’t quit nursing. As so many other people have said in their comments, there are many other nursing jobs for a Registered Nurse.
As for the page of orders - I agree with Karen, it was a system error. It is something that needs to be reported to your facilities QA (quality assurance) or QI (quality improvement) team. If it happened to you, chances are it has already happened to somebody else, and/or it will happen to someone else in the future - possibly with more devastating effects to everyone involved. Every healthcare facility has one of these teams, though it may be called a different name, it is required by federal law…trust me, I know- I am in charge of running the QI team at my facility.
March 23rd, 2008 at 12:49 am
“I’m singing in the rain (kick!)
Just singing in the rain (slap!)
What a glorious feeling (crunch!)
I’m happy again (Kerpow!)
I walk down the lane (Boff!)
With a happy refrain (Slam!)
I’m singing, singing in the rain
In the rain.” (Kickety-kick-de-kick-kick.)
Job well done, droogs.
March 26th, 2008 at 4:32 am
awe I hope you don’t quit nursing. Although nursing is quite frustrating I agree but think of the other fun times you have had working in the hospital.
And don’t dwell on missing those orders, we all are humans after all. We make mistakes, that’s inevitable. Besides, you had more better things to do than waste your time looking for hidden orders.
May 15th, 2008 at 2:15 pm
I think its ok that you shifted from Nursing and started with this blog. But still nursing is not just a job where you have to carry out orders from doctors or seniors. Moreover its a job where we are helping the patients and affected ones. Please don’t forget the humanitarian aspect of nursing profession.