THE GOOD NURSE

CCR Hot Topic - November 2022

Mary and I watched The Good Nurse,

released on Netflix this past week. It stimulated a healthy discussion around some practices we often see in nursing and pharmacy departments.

One of the big things we both noticed was how the liter IV bags stored in the med storage room on the ICU unit were all removed from their outer packaging. We hope it is not common practice to see this these days (note that these events took place in 2003). It is best to remove the outer packaging right before the time of use, when a nurse needs to spike the bag with tubing for a patient or before the pharmacy adds medications or electrolytes when needed. Once the outer package is removed the bags have a limited shelf-life, so always check with the manufacturer on when they should be discarded if not used.

The outer wrapping aims to protect the bag from contamination and moisture. However, it also offers a sense of tamper-proofing. The outer wrapper should make staff feel safe about using a bag since no one would have been able to access the injection port to add anything.

The movie also discussed leaking bags. If Charlie was puncturing the bags to add the insulin and digoxin to them and replacing the bags in the med room, wouldn’t they leak? Depending on the needle size and if little to no pressure was applied they might not leak. It is crucial to perform a squeeze test before the pharmacy adds medications to an IV bag and before they release a final compounded IV bag. This task must be included in the pharmacist's final visual inspection. The squeeze test must also be performed before a nurse hangs an IV bag for a patient. Make sure your standard operating procedures and training address squeeze tests.

The other big thing was Charlie's workaround method to take medications out of the Pyxis machine. It seems that the hospital at that time did not have the medication cabinet linked to an electronic health record or medication administration record therefore, reconciling medications withdrawn from the cabinet by linking them to an actual order for a patient could not be performed electronically. In those days, we often saw pharmacy or nursing staff having to reconcile these records manually.

Since Charlie was canceling the dispense, it allowed him to still have access to the drawer opening and the medication but also canceling it showed in the records as if no meds were taken. Someone should have been tracking cancelled transactions for trends of suspicious activity.

Nowadays, with the hospital information systems (such as Epic, Cerner, etc.) it would be even more challenging to “take medications” without it being linked to an order. It is possible, though and this comes in the form of override capabilities. Computerized provider order entry (CPOE) verification turn around time may not support the fast pace workflows of codes and overrides which can make a difference in good vs. poor outcomes.

Another option is to require a witness when removing a medication on “override”. Witnessing overrides in fast pace workflows like codes may not be feasible especially in areas where staffing shortages or high patient loads exist. It is essential to monitor and reconcile overrides frequently and according to your facilities procedures. Pharmacy staff members and nursing staff need to be diligent about inventory and reconciling unlinked orders. The movie made us think of the Institute for Safe Medication Practices and the great guidelines they have for automated dispensing cabinets (ADCs) that should be reviewed by all involved departments for ideas to improve ADC use. See Guidelines for the Safe Use of Automated Dispensing Cabinets February 7, 2019.

We are dumbfounded that hospitals would ignore what Charlie was doing to avoid negative publicity. How could anyone ignore that a nurse is killing people and let them go so they could work for other facilities where they could kill more patients? It amazes us that none of those facilities have faced any consequences. So, what can we do to be a good pharmacy technician, pharmacist, or nurse? Be proactive and if you see something say something.

Please share your thoughts on the show and ideas to prevent these circumstances in the comments. We look forward to a health discussion with you too.