PRESCRIPTION ERRORS

When I go over to Shelby monthly to get my blood pressure med at Pamida, I think of my months working at that county’s nursing home because Janet, the pharmacist, was the pharmacist at the Care Center complex during that time period. She’s one of those centered, attentive, intelligent beings that one really WANTS to have as a pharmacist so I’m always happy to see her.

However, I’m not so happy when I think about my brief career as ward clerk several years ago. There were four applicants for the job and since I was the only one who had ever used a database, I was hired. In this state one can be dismissed for no reason at all until one has passed the probationary period of six months. This job had been originally set up as a half-time job because the regular ward clerk had begun to show physical signs of stress, like possible angina. She was excellent, conscientious to a fault, and educated to be a lab tech so she had exactly the right kind of personality, enculturation, and standards. (I wasn’t even an “English major” but rather a secret theatre major -- total mismatch for record-keeping but it had been just right for my previous decade as a minister.) We were both named Mary.

That Mary threw a loop into the rope when the process of hiring me was almost complete -- she declared that SHE wanted the half-time job rather than the full-time job. So here I was with a full-time job for which I was unsuited. It got worse.

The way drugs are administered to the patients, mostly elderly in this nursing home, was that the ward head nurse (there were two wards) had a cart on wheels with drawers in it. Each patient had an entry in a 3-ring binder which told the nurse which meds each was supposed to get, usually at meals, and the meds were in the drawers in bubble packs of the stipulated dosages. The cart was locked into a special meds room when it wasn’t right with the head nurse as she gave out the pills. I had a key to the special meds room so I could go in and change the 3-ring binders when necessary.

There were a couple of bugaboos: one was that narcotics would be stolen and the other was that a patient would be given the wrong meds or the wrong dosage. Recently there has again been publicity about how often people across the country are given the wrong meds and the damage it does, but I hardly saw that. Instead, what I saw was that these nurses were mostly local, had known these people by name for decades (might even be related), and were well aware of what they were supposed to take and what it was for. In fact, the nurses often caught errors that the doctors made.

The other Mary was vigilant and effective. She not only kept all the drugs straightened out and the 3-ring binders up-to-date, she also cleaned up the nursing stations -- especially when she came first thing in the morning -- and maintained a big blackboard full of notes about individuals in the break room. The nurses interpreted the ward clerk as a person “who has nothing immediate to do,” and would often try to get the ward clerk to push patients in wheelchairs over to the doctor half of the complex or pick them up after they had been tended to. Mary managed to not do that without offending anyone. I never figured out how to do that.

The biggest problem was intake, when a new person came into the wards. Finding out, recording, learning the new routine was always a half-day ordeal. Everyone was overloaded, the doctors were slow to make decisions, new questions arose, and though most people who came in were too sick to protest, a few of them had demands. The checklist Mary made for me was two pages long. It seemed as though I always let something slip by me. Mary often came back after supper -- she lived in Shelby -- on exceptionally busy days, so that she could give another check to her own work. I lived thirty miles away and was not about to come back in a blizzard. Mary was a dedicated Baptist, whose life was a living testament to her concern for what is right. I, this Mary, am also religious, but in quite a different way.

Most of the mistakes made were along the lines of missing a pill or giving a slightly wrong dosage. Most of the management concern was along the lines of not providing grounds for a lawsuit -- not for killing a patient. Sometimes (rarely) nurses deliberately gave meds not prescribed, for instance when someone was in extreme pain but didn’t have bubble pack for that and no doctor could be found. They’d just borrow a bubble and break it open, then put it down as lost.

It seems to me that the present publicity about drug errors is meant to echo the New Orleans case where patients were actively put to death since they were already teetering on the edge and would otherwise face the torment of heat or possibly drowning.

In this Montana nursing center an in-house laboratory produced overnight blood and urine scans constantly. The most common life-threatening problems I saw were not pill mistakes but rather bladder infections or blood poisoning. Scrubbing and maintenance of aging facilities was a problem. The ward clerk kept track of patient bathing but could do nothing about broken lifts or creeping mold in the damp windowless bathrooms.

Nurses were under incredible pressure. Many had children, had to work more than forty hours a week, and were single parents. Several were wives of ranchers and some were the sure-enough rancher themselves. A fiendish management tool was the “traveling nurses,” who were nurses who worked as temps, coming in cold (often quite literally in winter) from hundreds of miles away (often from Canada), not knowing even the other nurses much less the patients, staying only a day or so in impromptu dorms, often exhausted, the backs of their cars piled with clothes. On the one hand, the records in the binders on the drug carts were critical -- they had no other real guide -- but on the other hand, they had no reason to question what they read, to cooperate with the ward clerk, to pick up the additional information that circulated without being written down. “So and so seems exceptionally weepy.” “I think Mr. X is hurting, but he can’t say how.” The Director of Nursing had standing orders to simply fire any insubordinate employee on the spot. With travel nurses at hand, there was no problem with staffing gaps. Theoretically.

But the people who turned over even more quickly than nurses were the “Certified Nursing Assistants,” an assorted lot who ranged from angels of mercy to shady guys the nurses said would feel your butt, given a chance. Who knows what they did to the patients. Everyone seemed resigned to them because they were big and strong, could turn patients over single-handed. I turned one in for cursing out a little victim of MS and throwing her wheelchair seatpad against the wall. He was fired on the spot. Everyone was mad at me, including the patient, who feared making trouble.

The nursing supervisor was madly in love with some guy in the Flathead Valley and was rarely on the premises. One of her last acts before being fired was to fire me. She almost immediately got another job because there is so much need for people with her qualifications. The new one turned out to be much better. The other Mary went back to full-time. At least at that point I qualified for unemployment.

A major to-do is being made about economics splitting out so that the top keeps making more and more money, the bottom gradually sinks deeper into poverty, and the middle-class is flat-lined. Today on “Here and Now” Paul Krugman repeated the same warnings he gives over and over again. For a taste of him (in case you can’t afford to be a NYTimes “Select” reader) try this url: I’m absolutely convinced he’s right in just about every dimension.

But also, this business of “mistake-proofing” meds in hospitals is a good example of enticing the innocent into spending huge amounts of money on complicated computer software that isn’t really up to the task. I could barely understand the system in place. After they upgraded it, there was no one in the whole Health Center who really understood it -- including the so-called computer expert. If you were much of a computer expert, would you settle for a deadend job in a High Line Montana nursing home in a town with two economic resources: a train/truck interchange and a for-profit prison?

That in itself is bad enough, but in promising that all would be solved by Hal the Computer, the management assumed they could justify raises for themselves because nurses could be laid off -- and those pesky CNA’s. The computer would take care of everything. So the money goes to some tech company with ghosts in carrels pumping out code, and NOT to the patient’s niece who has struggled her way through training because she believes that nursing is a sacred calling.

Most people around here don’t want to hear me raving like this. It’s too scary. They don’t know what to do about it. Luckily, there was a trucker from Salt Lake City waiting for the pharmacist at the same time I was. While he drives he listens to streamed radio via modem from across the country and even across the globe. He thinks NPR is insipid and the Clear Channel world is corrupt. He understood exactly what I was saying.

I don’t know how much Janet, the pharmacist overheard. Her assistant, a young woman, was staring wide-eyed, then remembered herself and pretended she didn’t hear anything. It’s not a strategy I admire, but it works in the short term. I just think we need a much stronger prescription.