Warning: Your boarded patients may be missing life-saving medication dosages

Scheduled meds not always given

Editor's Note: This is a two-part series on medication safety for inpatients being held in the ED. This month, we give strategies to avoid missed dosages; next month, we'll cover how ED nurses can reduce errors with inpatient medications.

When an inpatient is boarded in your ED for hours, do you have a process to ensure their timed medications are not overlooked? "ER nurses are used to giving meds as soon as they are ordered. Our work flow typically does not include scheduled meds," says Melanie Gullixson, clinical director of the ED at St. Joseph's Hospital ED in St. Paul, MN. "We have to think differently when patients are being held."

Bad outcomes can occur if a patient misses even a single dose of a time-sensitive medication, warns Gullixon. A missed dose of furosemide could cause fluid overload, and any missed blood-pressure medication can cause dangerously high blood pressure, says Gullixon.

"A missed nebulizer treatment could cause a respiratory issue, missed digoxin could cause a rhythm change, and missed warfarin could cause a decrease in INR [international normalized ratio]," adds Gullixon.

Leighann Kristin Flanagan, RN, CEN, clinical educator/supervisor for adult emergency services at Wake Medical Center in Raleigh, NC, says it's not uncommon for an ED nurse to be responsible for several boarded patients, as well as other patients with high-acuity illness or injury.

The ED, says Flanagan, is a "high pressure environment with frequent interruptions," and could cause a patient's timed medication dose to be missed.

Medications are timed to ensure that there are sufficient levels in the patient's bloodstream, adds Flanagan, and may need to be timed with meals for proper absorption.

"Pain medications are timed so that the patient receives a dose before they begin to experience intense pain," she says. "Missing doses of regularly taken medications can cause uncomfortable side effects."

If a patient misses timed doses of a medication for seizure activity, says Flanagan, this places them at risk to have a seizure. Likewise, missed doses of blood-pressure or heart medications may mean extra workload on their heart, she says, and missed anticoagulant doses could result in a blood clot forming.

Wake Medical's ED nurses keep boarded patients separate from acute-care areas, says Flanagan. "We attempt to make our patient-care assignments such that the nurses caring for boarded patients can avoid caring for acutely ill ED patients as well," she adds.

No hunting for meds

"Being a small community hospital, our patient load increases greatly when it is flu and cold-weather season. Therefore, our admissions max out," says Tammy Johnson, RN, BSN, an ED nurse at Carteret General Hospital in Morehead City, NC. "We do hold inpatients in our ER for several hours." Here are some ways ED nurses avoid missed medication dosages:

Stat orders are flagged.

"These are to be done or carried out within one hour, and medications are faxed to the pharmacy within two hours," says Johnson. For example, a patient on warfarin may have a stat order for a prothrombin time/INR test, she says, or a pneumonia patient may have orders for stat antibiotics. 

Medications for boarded patients are kept in a separate automated medication dispenser.

"It is located in a central location separate from the regular ER Pyxis," says Johnson. "This has decreased medication errors due to not hunting to find the med or pharmacy tubing half and then later receiving the others," says Johnson.

It also prevents dosage timing errors because when an ED nurse pulls a medication, it indicates when the last time that med was pulled, adds Johnson.

Johnson says that there are sometimes delays from the time the medication is ordered to the dispenser being stocked. "Our pharmacy works very hard at getting medications, especially the essential meds, to us in a timely manner," she says.  

The ED's EMR system prints out a medication administration record (MAR) with the time indicators.

"This assures we are giving the meds on schedule," says Johnson. "Our EMR has a different set of templates for the emergency room and floor. The central MAR shows all the medications the patient has received."

Dosages are documented.

"We are working at educating all staff from the accepting floors and ER on where to check for documentation that meds have been given," says Johnson. "This decreases the risk of double giving medications." (See an important question to ask your patient and related story on documentation of inpatient medications, p. below.)


For more information on medications given to ED-boarded patients, contact:

Leighann Kristin Flanagan, RN, CEN, Adult Emergency Services, Wake Medical Center, Raleigh, NC. Phone (919) 350-2889. E-mail: Iflanagan@wakemed.org.

Tammy Johnson, RN, BSN, Emergency Department, Carteret General Hospital, Morehead City, NC. Phone: (252) 808-6133. E-mail: teturner@ccgh.org.

Melanie Gullixon, RN, Clinical Director, Emergency Department, St. Joseph's Hospital St. Paul, MN. Phone: (651) 232-3555. Fax: (651) 864-0741. E-mail:mgullixson@healtheast.org.

Clinical Tips

Ask boarded patient why they take meds

The majority of medications you administer to boarded patients are ones they take on a regular basis, notes Leighann Kristin Flanagan, RN, CEN, clinical educator/supervisor for adult emergency services at Wake Medical Center in Raleigh, NC. "Ask them if they are familiar with the medication," she advises. "Are they aware of the reason they are taking it? This is a safety check, as well as a teaching moment."

Document this about inpatient medications

The need to transcribe, administer, and document timed medications in a busy ED leaves admitted patients "particularly vulnerable to a drug error," according to Leighann Kristin Flanagan, RN, CEN, clinical educator/supervisor for adult emergency services at Wake Medical Center in Raleigh, NC.

Many times, says Flanagan, the emergency nurse must order a medication from the pharmacy, and it's not always obtained in a timely manner.

"The ED nurse is presented with hand-writing a patient Medication Administration Record [MAR] with the correct medication, dosages, and times, per the hospital policies," she says. "ED nurses do not have a lot of experience with this type of transcription."

Inpatient order set utilized

Melanie Gullixson, clinical director of the ED at St. Joseph's Hospital ED in St. Paul, MN, says that one problem in her ED is that the ED's electronic medical record (EMR) doesn't "talk to" the inpatient electronic record, and vice versa.

"So we work off the ER record. If the attending writes orders, we work off of the paper orders," she says.

If the attending hasn't seen the patient yet, then nurses use the ER bridging orders, and use pen and paper to keep track of what needs to be done, says Gullixson. "We rely on the nurses following a process of utilizing the inpatient order set to get and give the meds," she says.

If the patient is boarded for a prolonged period of time, ED nurses make sure to contact the attending physician to get the scheduled orders, Gullixon says. Otherwise, she says, "the attending doesn't often come down. A big reason meds are missed is that they simply aren't ordered."

Since the ED doesn't have an electronic inpatient record available, the ED's EMR is used, explains Gullixon, with paper documentation of the next dose. "This is similar to the way inpatient nurses keep rounding notes on their patients in their pockets," she says. "We then transcribe the order into the ER's EMR to give the med."

Always be sure there was a double check with the MAR against the original physician order, warns Flanagan. "Many times, an error occurs when the order was not correctly transcribed," she says.