• Right patient
• Right drug
• Right dose
• Right route
• Right time

However, medication errors still happen, and not infrequently. Nurses are busy, and we are getting busier with increasingly sicker patients who require increasingly dangerous medications. The five rights deserve a little extra attention. It never hurts to go back to the basics.

The right patient. Do you check your patients’ armbands? I start every single assessment this way (“please tell me your name, birthdate, and drug allergies”), often to eye-rolling annoyance, but I catch misbanded patients and those with erroneous registration information. It’s a simple thing that gets left out. If your hospital uses scanners, for heaven’s sake scan the bracelet and not a bar-coded sticker lying around on the counter. If the patient is misbanded or not banded you’ll be stopped right there.

The right drug. Pharmacy departments like to mess around with “tall man” lettering and easily confused medications, and that’s good, but there are sneakier ways to get tripped up here. Do you grab a vial out the Pyxis and not check the label because you’ve grabbed Zofran out of that slot every single shift for 5 years and it has a blue label? Bummer if it was stocked wrong and you just overdosed your patient on Dilaudid. Does the drug make sense for your patient? If not, check. Docs can click the wrong box and order the wrong drug or order the right one on the wrong patient.

The right dose. Ah, the magic of calculators. But first, check labels. Pharmacy may switch things up on you. Ours likes to keep us on our toes by switching 50- and 100-mcg Fentanyl syringes. Happily, they stick green dosage warning labels everywhere. If you’re not using the entire unit dose, double-check. If you’re giving it to a child or if the drug is a pressor, insulin, or heparin, double-check with another nurse. The right dose also includes rates for IV fluids. Were fluids at 100 mL/h ordered but you bolused it? Bummer if that sends your patient into heart failure. Check, check, and double check, and if the ordered rate doesn’t match what seems reasonable for your patient’s condition, ask!

The right route. Lots of drugs come in multiple forms these days, especially with the current drug shortages, but even in general physicians occasionally order drugs via an unusual route. If in doubt, ask. If you have never given the drug via that route (e.g., you are giving a drug IM that you usually give IV), use the power of your drug reference of choice and read about it. Anyone ever given dexamethasone by fast IV push? The effect is notably different from when it is given orally (it causes intense rectal itching).

The right time. Usually there is a window during which medications are considered “on time.” Aside from keeping the bureaucracy happy, though, giving medications at the right time may not be exactly when they are ordered. Nursing judgment is required. Probably do not, for example, give that Cardizem bolus to your patient whose heart rate is now 60 and BP is 86/40, even if it was ordered for “now.” For some medications, timing is unusually critical; for pneumonia, sepsis, and chest pain/stroke protocols, “now” actually does mean now. These folks need antibiotics, fluids, or whatever right now. Now. (And please document exactly what time you gave it, for everyone’s sake.)

These are things nurses know but rush through. If we take a few extra seconds—it really is seconds—we can give patient safety a huge boost.

This is a subject that has needled me for years. I wrote a paper in nursing school about nursing communication around unconscious patients, and there was very little research on it to be found. The studies I located indicated that many patients do hear us even when they appear to be unresponsive, and conventional wisdom says that hearing is the last sense to go. Recently I read My Stroke of Insight, by Jill Bolte Taylor, on the recommendation of a friend who’d had a stroke. The author, a brain scientist, repeatedly recounts stories of hearing nursing staff talking around her when they thought she couldn’t hear them. The stories fascinated me, but they also made me think, “Uh oh. What have I said around people?” The author relates that she could tell which nurses were present with her and which were just doing a job. I want to be present for my patients, even the ones who I’m not sure are present.

I really think we need to think about this topic. It’s so easy to get accustomed to thinking of an unresponsive patient as somehow not there. Nursing and ancillary staff almost default to talking about these patients as if they are definitely not conscious. It’s easy to do, because we forget about people who aren’t moving and talking, particularly if we have deliberately sedated them.

But how frustrating and possibly humiliating would that be if you were that patient and you could hear the staff talking? We know on some level that they might hear us. I noticed once during a code that nurses were taking the trouble to move away from the patient and whisper about the dire nature of her labs and so on; we instinctively did not want to mention in her hearing that we thought she was going to die imminently. Other times, though, physicians and nurses speak freely over an unconscious person. How terrifying to hear things like, “This guy is hosed.” Patients don’t know that we use black humor to get by; they know only that we sound uncaring and uncompassionate.

What can nurses do to improve our communication with unconscious patients?

1. Assume everyone is conscious. If you wouldn’t say it to an awake person, don’t say it to an unresponsive one.
2. Announce yourself when you walk in the room. It is startling even when you are asleep to have someone sneak in on you.
3. Explain to the patient what you are about to do. Say, “I’m going to suction your breathing tube so you can get some more air” or “Your IV has gone bad, so I’m going to start a new one. You’ll feel a stick when the needle goes in.”
4. Orient the person. “You are in Happytrails Hospital, and it’s Monday, January 1. You are here because you fell and hit your head. Your family will be here to see you in 2 hours.”
5. Don’t be crass. I’m an ER nurse and am guilty of as much crassness as anyone else, but it’s a bad habit, it’s unprofessional, and it’s not OK just because the patient seems to be sleeping peacefully.

I have noticed that our new Foley packaging includes a big orange piece of paper that says “PLEASE CONSIDER WHETHER THIS CATHETER IS NECESSARY” or some such. I investigated. I knew that hospitals are going to be nailed for hospital acquired infections, and indwelling urinary catheters are a huge culprit, but I dug around a little more.

Turns out that infections from urinary catheters are the most common infections that patients get in hospitals, and despite campaigns to increase hand hygiene, perineal care, and aseptic technique, the infection rates are not getting any better. Therefore, the drive is to use fewer urinary catheters to begin with (Jim Kling, “Protocol Reduces Use of Urinary Catheters, Infections,” Medscape Medical News, April 3, 2011, accessed at http://www.medscape.com/viewarticle/743452; free account required to view).

See also “Facts About Foleys” here. Notably:

• “38% of indwelling urinary catheters inserted in the hospital have no justifiable medical indication.”
• “The risk of developing a catheter associated urinary tract infection increases by 5% for every day the catheter is in place. Long term use (over 28 days) has a 100% infection rate.”
• “Each catheter associated urinary tract infection (CAUTI) costs a hospital approximately $3,383 to treat plus up to 4.6 additional hospital days.”

The “no justifiable medical indication” grabbed my attention because it related to my colleague’s comment that “incontinence isn’t enough” and also to that long-ago resident who would ask if the Foley was for me or for the patient. What are justifiable medical conditions? Late-stage pressure ulcers, surgical hip fractures, and so on. Not weakness or a desire not to keep getting up to use the commode (I hear my nursing instructors droning in my head “no one ever got better lying around in bed!”).

This strikes me as a minefield. What of the patient who is too weak to get up but does not meet the criteria for a Foley and therefore lies in urine and develops pressure ulcers? Then she will meet criteria, only she will have two hospital-acquired issues that are expensive and painful.

Nevertheless, nurses already have a role in the fight against catheter-associated urinary tract infections. We can question orders for them that don’t seem appropriate: especially since order sets involve checking boxes more often than not, physicians may just reflexively check the box and be happy you pointed it out. We can educate patients on the pros and cons. They always have the right to refuse. We can, of course, be as meticulous as possible about our sterile technique and follow-up peri care, and we can ensure that catheters are removed as soon as possible.

I have a feeling that urinary catheters are on their way out except in surgery or strange cases such as neurogenic bladder. Until then, they’re going to cost hospitals a lot of money, and it will fall mostly on nurses to help soften the blow. We need to educate ourselves, our colleagues, and our patients about these infections and ways to avoid urinary catheter use.

1. Show up to work drunk or high. Sounds obvious that you’d want to avoid this, but I’ve seen it happen. It’s best to avoid a problem with drugs or alcohol just on general principles, but if you have one, deal with it outside work and don’t clock in with substances on board.
2. Steal narcotics. Again, this sounds obvious, but apparently it needs to be stated. I’ve been a nurse for only a few years, and I’ve seen two nurses get into deep trouble for doing this. They were both pretty creative about it, too. The state board will usually give you your license back after you go through their program, but try getting a job with a narcotics diversion on your record.
3. Do stuff outside your scope of practice. I’ve said it before, and I’ll keep saying it: read your state’s Nurse Practice Act. Then read your hospital’s policies for iffy areas. If you find yourself in front of a peer-review board being asked, “What made you think this was a good idea?” it’s best to have an answer. Example: at my first job, we pulled PICC lines daily. At this hospital, it’s not in an RN’s scope unless she is infusion-certified, which I am not, so if I pulled a PICC line and something went wrong it would be a much bigger problem than simply harming the patient (which is bad enough).
4. Violate HIPAA. Hospitals aren’t kidding about HIPAA. Patients ultimately cannot bring complaints against you; it’s against the institution you work for. So they will come down on you like a ton of bricks. This does not mean never talk about your job or patients. It means never talk about your patients in ways that other people can identify them, and while you’re at it it’s probably a good idea to avoid bashing your job publicly by name—that isn’t a HIPAA issue, but I’ve noticed that these issues tend to go hand in hand, and both will get you fired. Depending on the egregiousness of the violation, your state board can get involved, and it’s a good rule of thumb to avoid having to deal with the state board.
5. Do something wrong that injures or kills someone, AND display a lack of remorse. It’s a sad fact that nurses are human and will make mistakes. Of those mistakes, some cause harm to patients. The discipline generally depends on the egregiousness of the harm caused, but it also seems to often depend on the degree to which the nurse in question is honest about the error and commits to remediation to avoid repeating it. Getting defensive and lying about the errors you make is a really, really bad idea (see “avoid dealing the state board,” above). If you make a mistake, tell your charge nurse and/or nursing supervisor and do what they say to take care of it.

They are important, and therefore we need to take them and interpret them, which means they need to be accurately and appropriately measured. This is a loaded statement. Let’s take it apart.

Vital signs need to be accurate. Is your CNA taking them? Do you know that he or she is doing it correctly? You’d better, because you’re still responsible. Is the patient lying on her side? Is the cuff the right size? Is the oximeter on a finger with poor circulation? Did the patient just drink coffee or ice water? All of those things can throw off vital sign values to the point that they become completely useless for clinical decision-making.

Vital signs need to be appropriately measured. Does your patient have chest pain and a history of aortic dissection? If so, vital signs probably need to be taken and recorded more often than every 4 hours (much more often). Does your patient have a hangnail? If so, you probably have better things to do than take his vital signs hourly while he waits for more emergent cases to be seen. What is appropriate? I can’t find any standards. Guidelines, yes. But at baseline, nurses need to use our brains. For example, if a patient becomes unstable, increase the frequency of taking vital signs no matter what the order says. Appropriate measurement may mean wildly different things to different specialties. For example, if I have a patient who is finally getting some sleep and has been stable, is it appropriate to wake her up every hour just because I need to document something?

Finally, we need to interpret them. Having a list of values is useless unless we look at trends. What is the MAP? The pulse pressure? Is the blood pressure trending up or down? Did that fever get better after Tylenol? A 10 mm Hg difference in 4 hours may seem trivial, but a 20 mm Hg drop after 8 hours can mean your patient is headed for septic shock and you weren’t paying attention. A monkey could probably be trained to take vital signs, so our nursing knowledge and experience must come into play to interpret the data and act accordingly.

Vital signs are important: let’s not skip their relevance because they’re so common in our task lists. This is a nursing judgment issue; our job is not just to take vital signs by rote. It is to take them according to the patient’s condition and interpret them so that we can make decisions and inform the decisions of other healthcare providers.

Hospitals increasingly refuse to hire LPNs. Why? Because their scope of practice is such that it ties up an RN to supervise what they do, and that is just not efficient in these “do way more with much less” times. An LPN used to be more helpful to RNs and the healthcare team, but often now the time required from an RN to supervise an LPN is simply not worth it. My hospital uses LPNs in some areas and has grandfathered some in elsewhere, and they tell me it has gotten to the point that they feel like glorified CNAs. Also, as an RN, I do not like having to supervise LPNs. I have little experience with my responsibilities doing so, and I tread carefully when other people are practicing under my license. I will not simply sign off on an LPN’s assessment unless I have seen the patient myself, and at that point I feel I might as well have done the whole thing myself. I doubt that I am alone.

LPNs, in my view, should give themselves the benefit of the RN after their name. The ones I have worked with generally have many years of experience and often are better nurses than I am, but because they lack two letters after their name they make less money and have severely limited career opportunities. Isn’t it worth a year or so of sacrifice to dramatically improve job satisfaction?

But let’s look at the sacrifice part. Bridging from LPN to RN generally takes a year, and bridging from LPN to BSN can take one to three years. Averaging tuition across the nation is meaningless because of cost of living and many other factors, but you can check your local colleges and community colleges to check tuition costs with a 15-minute web search. Don’t forget books and supplies; nursing education books are notoriously expensive. Also factor in childcare and decreased work hours if you are currently working full-time. And that’s just the financial side. Nursing school is hard. The actual school part is hard, and it takes a toll on family and personal life. Going to school, juggling clinical hours and probably a job at the same time, and setting aside time for friends and family can be a nightmare, and looking at up to three years of that can be truly daunting. Some programs allow you to go part time, but many don’t; it’s all or nothing. My school was pedal to the metal, and I doubt that’s atypical.

Is it worth it? That’s an individual decision, but it’s worth considering. Carefully.

Between the cardiac ICU, where everyone needed Foleys because they had to lie flat for a long time, and the ER, where we get a lot of elderly patients with hip fractures who need Foleys, I’ve developed a decent arsenal of tricks not to be found in any textbook.

1. Put the bed in reverse Trendelenburg for women. This lets gravity help you and the patient. Elderly folks have stiff hips and weak muscles, and leaning back helps them let their legs fall open. If the patient has respiratory issues, you can also leave the head of the bed raised somewhat while you insert the Foley so your patient isn’t blue when you’re done.
2. Also for women, use the “wink” to find the urethra. It’s not so easy to find on a real person sometimes, is it? Pro tip: use your Betadine swab and run it straight down toward the vagina: usually the urethra will wink at you.
3. Another female trick: don’t get too lube-happy, and get a short grip. Hold the tube only about a half inch from the end when you approach the urethra. Otherwise the thing has a tendency to snake into the vagina at the last second.
4. For men and women, remember the oft-neglected Coudé catheter. It’s got a stiff curved tip and is known to be helpful for navigating the prostate in men, but many older women have a urethra that is nearly in the vagina. You can use an upward-pointing Coudé tip to defeat this anatomical trick. For truly difficult anatomy, have another nurse insert a finger in the vagina and slide the cathether over it straight into the urethra.
5. Men only: approach the penis with confidence! Get a good firm grip and hold it perpendicular to the abdomen. If you don’t start out this way the skin will fold up on you and you will, pardon the pun, be hosed. And speaking of skin, if the patient is not circumcised, please remember to be a good citizen and put things back the way you found them (replace the foreskin).
6. Once the catheter is in, secure it with a stat-lock or leg band so it doesn’t get yanked out. If the patient has truly awful bladder spasms or ones that last beyond 30 minutes, investigate whether your facility has B&O (belladonna and opium—no, I’m not making this up) suppositories. Many physicians have never heard of them, but pharmacists can dig them up, and they work really well for post-Foley discomfort.

And there you have it…a bag of tricks to make at least one task easier on both nurse and patient.

Still, I don’t think it has to be. I ended up enjoying my nursing home rotation in school. Things about it made me feel sad and upset, but I rarely go through a shift anyway without feeling like that. I was surprised that I enjoyed the elderly population, so I can’t help thinking that instead of the “well, there’s always long-term care,” attitude, a better one might be “try it—you just might like it.” Here are six reasons why:

1. They have often thrown to the wind any caring about what people think, and therefore they say exactly what they mean. I find this refreshing. I remember a lady who swore like a sailor when she missed her eye with her glaucoma eyedrops. A sailor might have even blushed. She was wearing pin curls and lipstick. She wasn’t demented; she just didn’t care.
2. They have really good stories. Even elderly with relatively advanced dementia can recall events from the distant past, and it’s good for them to do so, so it can be justified as therapeutic to ask. I once got a breathtaking recreation of the Spanish flu because I asked about it.
3. This is a specialty population, and nurses can develop a sense of pride in becoming expert in their care just as they can with pediatrics. I guarantee you that when the elderly are in traumas or go into anaphylactic shock or get plain urinary tract infections, the clinical picture is far different from that of a 30-year-old. Knowing that, realizing the problem, and knowing why can drastically improve the quality of life for the patient, who doesn’t have to wait around for us to figure out what’s going on.
4. It’s someone’s parent. Yes, this is sentimental, but the elderly have put some miles on them. They may have fought in wars, most have raised families, and many have lost members of those families. Call it karma or responsibility, but when I care for elderly patients, I hope that when my family members grow old and sick, someone takes good care of them too.
5. You will stop fearing death so much. This is not something I set out to do when I became a nurse, but it’s an unexpected bonus. Nurses wade around in death of all kinds, but the elderly tend to be more practical about it. When told of a quickly fatal diagnosis incidentally discovered on imaging exams in the ER, one of my elderly patients recently shrugged and said, “Well, you have to die of something, right?”
6. You will reconsider how you live your life (also not something I set out to do when I became a nurse). After you have cared for many elderly people and likely attended their deaths, it’s difficult not to be drawn into wondering what amends, regrets, and triumphs YOU will have at the end of your life.

Nurses don’t have to work in long-term care to work with the elderly. Plenty show up in the ER, on any hospital medical floor, and in the ICU. Pull up a chair and chat with your elderly patients while you give meds. You might find it rewarding.

1. Although it’s good to share, it’s better to keep germs to yourself. I become annoyed when I have to work next to sick colleagues. I envision bacteria swarming all over the nursing station and feel like bathing in bleach when I go home. It’s just not polite to deliberately put your coworkers at risk of getting what you’ve got.
2. Failure to adequately rest and treat an illness will likely result in its lasting longer anyway. Would you rather take 24 hours to stay in bed and take care of yourself, or would you rather take a week to get over an illness that got worse because you didn’t? I hate being sick, so I’ll take the 24 hours, thanks. This makes financial sense too. Does the hospital want a nurse out for one shift or three? I’m guessing one.
3. Our patients have enough problems without having a sick nurse on top of it. I would be mad if I went to the hospital and came away with yet another health problem given to me by my nurse. Some patient populations are truly at risk from microbes, too. If you have a fever and work with postoperative patients or those with immune system compromise, you may literally be putting their lives at risk by going to work. And don’t cheat by taking Tylenol and saying you don’t have a fever. Nurses should put patients first in every way, and to me obviously that should include not making them sicker than they were to begin with.
4. Sick nurses are preoccupied with feeling sick and may be taking cold medicine or other over-the-counter medicines that dull their reaction times. This sets the scene for medication errors and failure-to-rescue scenarios. Being sick causes inner misery. I don’t care how driven you are. If you’re trying not to throw up, you’re just not going to be paying enough attention to your job. If you’re an accountant, that may be OK, but if you’re a nurse you need to be on your game.
5. Staying home unapologetically when we are sick starts to send the message that we are not bad, lazy people for being ill. Going to work sick and dragging around wanting hero points does nothing but perpetuate these healthcare culture myths that need to go.

Am I saying nurses should stay home every time we get the sniffles or feel a little queasy? Obviously not. We do, however, need to weigh in the balance whether we are causing more harm by going to work sick.

You’re reading it now. I’ve heard various theories about why these medications are short nationwide, many of which conflict, but whatever the reason, we’re in deep trouble. I hate to admit this, but I’m sure I’m not alone: it’s all well and good to hear about crises happening other places, but it doesn’t seem real until it affects me. My hospital is just…out of medications that we need. The first pinch came when we had to visit several Pyxis stations to find any IV benzodiazepines for a patient having seizures. Well, that’s a problem, isn’t it? Since then the rule has been no benzodiazepines for anxiolysis or anything other than, basically, status epilepticus. We have had a lot of nervous patients with muscle cramps since then.

But now we’re out of Zofran. Out. Gone. Not “check another Pyxis” gone, but gone, gone. Zofran is a miracle drug in the hospital. No dyskinesia, no sedation, nothing except the tiny infinitesimal chance of a prolonged QT interval. Now we’re on to Compazine and Reglan. Big pain in the rear. Why? They have to be diluted and pushed very, very slowly to avoid a dyskinetic effect; they’re sedating; and they have to be given with Benadryl, which is also sedating. Not a problem for inpatients, maybe, but in the ED we have to consider how to get our patients home. Outpatient clinics may be in the same boat. Also, I’ve seen Compazine and Reglan on a lot of allergy bands, and I’ve seen Zofran on only two. What are we going to do if a trauma patient comes in vomiting and is allergic to all the antiemetics we have? I feel distinctly nervous.

What about Phenergan? It can be given IM but not through a peripheral IV because of the risk of extravasation. Patients don’t like it IM because it stings like heck. It is also incredibly sedating and gives patients a hangover feeling, which may not be much better than what they came in with.

Is this the first nip of the wringer in healthcare shortages? How inventive are we going to have to be? How can we give good patient care when we don’t have the drugs to do it? We need to be able to stop seizures and vomiting. Getting rid of vomiting sounds like a luxury, maybe, until you have a head-injured patient or one who is about vagal herself down into a cardiac arrest.

And what about patient satisfaction? “I had the stomach flu and they wouldn’t even give me anything for nausea because I didn’t have a ride home.” Patient satisfaction score: zero. Effect on hospital reimbursement: very negative. Anger at the messenger (always the nurse): flaming.

If this continues, nurses will be forced to be inventive, patient, and adaptable. To flog an adage, necessity is the mother of invention. Someone will come up with something. In the meantime, I think we’re in for a rough patch.