Just some rambling to the Google Doodle team on processes as I reflect after a long day.
Hard to believe it takes 60 actions to give one dose of IV Lasix. Did I miss any?
___
To: proposals@google.com
From: 12hourRN@gmail.com
Subject: Why Nurses Need A Google Doodle: Day 23 Thoughts
April 28, 2014. 11:28PM.
Hi, again,
Some nights, coming home from long days, household tasks are horribly hard. Living alone has its many luxuries; unwashed dishes excluded from this list. These nights, wiping crumbs off the kitchen counter feels insurmountable, forget sweeping the floor.
But tonight, for whatever reason, I’m enjoying the process of things. I washed the dishes slowly, drying each one instead of waiting for the air to do its work. The place and order of my kitchen was pleasing. I liked the way the silverware told me a story from its place in the drawer, the art and dishes making me remember the day of their purchase. Each thing special, in order, just so.
Perhaps this is the nurse in me – to love, and to hate the tedium of domesticity. Keeping a house clean is simply a series of systems – the toaster goes on the tray in the cabinet to the right of the sink, cleaned weekly depending on toasting frequency, with cord curled neatly beside it. The coffee stays in a glass, vacuum sealed jar next to the grinder, the sugar bowl in the fridge, the compost bin in the freezer. The garbage goes out each night, filled again with a grocery bag from the day’s purchases, sprayed with Clorox before re-lining.
These chores come easily when jazz is playing and a glass of wine sits within reach. I’ve created them, they are my procedures, if you will. They get tedious when I’m tired, when the steps outnumber my motivation. When I’m tired, I’ll quickly toss scraps in the trash, instead of opening the freezer, getting out the compost bin, placing it on the counter, removing the lid, adding the compost, replacing the lid, opening the freezer, putting the compost bin back into the freezer, and closing the door. The many actions required in the process outweighed the benefit of composting.
This happens at work all the time. I mentioned the other day the cleaning of the IVs. The simple act of giving a medicine, let’s say Lasix, a drug that induces diuresis, to a patient, is a process far surpassing my compost dilemma.
Here’s how it goes:
1. Receive order to give patient Lasix
2. Read order
3. Double check patient
4. Double check dose
5. Double check medical record number
6. Double check logic behind order (does patient need Lasix, is patient already peeing, does the patient have kidney problems, is this order written for the right patient, is there anything about this order I need to contact the physician about, is the patient allergic to Lasix, when was the last time they had Lasix…)
7. Review order by signing or clicking review on computer
8. Retrieve Lasix vial (depending on where you work, this step could add multiple other steps to the process)
9. Retrieve 5ml syringe
10. Retrieve access device (blunt needle)
11. Retrieve gloves
12. Wash hands
13. Dry hands
14. Don gloves
15. Open syringe packaging
16. Open blunt needle packaging
17. Remove cap on Lasix vial
18. Connect syringe to blunt needle
19. Insert blunt needle into vial
20. Aspirate dose of Lasix
21. Check dose of Lasix with vial and order
22. Appropriately recap blunt needle
23. Label syringe with time, date, drug and dosage
24. Remove gloves
25. Discard gloves
26. Obtain alcohol pads
27. Obtain saline flush
28. Open saline flush
29. Discard saline flush wrapping
30. Discard syringe wrapping
31. Discard blunt needle wrapping
32. Discard Lasix vial
33. Discard Lasix cap
34. Walk to patient room
35. Sanitize hands before entering patient room
36. Enter patient room
37. Put on gloves
38. Check patient identification band
39. Tell patient what you are giving
40. Tell patient why you are giving Lasix
41. Check patient vitals/general appearance to make sure administration appropriate
42. Locate IV
43. Open alcohol pad
44. Wipe IV according to policy
45. Wait for IV site to dry
46. Unclamp IV
47. Remove cap off saline syringe
48. Test flush IV with saline
49. Remove blunt needle off of Lasix syringe
50. Inject Lasix dose at appropriate rate
51. Flush remainder of saline
52. Reclamp IV
53. Discard alcohol wipes
54. Discard syringe in sharps container
55. Discard blunt needle in sharps container
56. Discard Lasix syringe in sharps container
57. Discard saline cap (yes! That has to go in the trash, too – they are deadly when stepped on!)
58. Smile at patient
59. Ask patient if they need anything
60. Move on.
Sixty steps for one drug. Imagine (not too hard, it happens all the time), you work on a unit without a fancy drug-producing machine, and you go to the place where you usually find Lasix, and there isn’t any! This throws off the entire process, and adds a whole new process into the mix – obtaining the medicine you need, and in a timely manner. What if you went to find the alcohol pad, and couldn’t find a single one? This is another process, or a way out of a process – like my quick dump of compost in the trash – just do without, don’t wipe, give drug, cut out at least five steps, it doesn’t really matter, does it?
Unfortunately, no unit is perfect, and just like at my house, systems get mucked up when people visit. These tasks, which seem simple, almost pleasant in their clarity, can become tedious and tiring when not all of the pieces are present, or when they are added to hundreds of others. It’s easy to ignore the benefit – patient safety – when the tedium overwhelms.
I’m not sure what I’m saying, except a general ramble on the complexity of life. Nursing or home, we run on the fuel of order. Its upkeep is pleasant and welcome when there is a warm breeze and peaceful feelings accompanying it. When the dog upstairs is barking, the soap runs out and the pile of dirty dishes seems too high, that’s when the system breaks down and we get tired enough to cut corners.
Who is to blame? Not sure. Just curious about the obscene number of decisions we as nurses make in a shift. I wonder how many innovate in positive ways, and how many are just a toss of the scraps in the trash.
‘Night,
Amanda Anderson, RN
Amanda J. Anderson 