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Bedpans and Bandages Episode 7: On drugs

April 1, 2014

Disclaimer: owing to the unavailability of Episode 7 of Bedpans and Bandages on ITV player, and the fact that a non-nursing friend chose to phone me for a chat just as the actual broadcast was getting under way, this review will be more than a little ‘impressionistic’!

Could there be a more eloquent illustration of how far the NHS has fallen behind in the IT revolution than the ‘Graham does the drugs round’ sequence in last week’s Bedpans and Bandages? It would have been laughable, if it wasn’t so typical. There were Graham and Sister Claire, backs to the patient, rummaging around in a wall-mounted drugs box while simultaneously trying to balance the hand-written prescription sheet on the too-small lid.

The drugs in the box didn’t match the drugs on the prescription sheet. After a bit of debate as to why this could be, it turned out that over-confident Graham had brought the wrong prescription sheet. Claire dispatched him to look for the right one, while hastily reassuring the (by now distinctly nervous-looking) patient that he was never really in any danger of receiving the wrong medication. Suitably chastened, Graham eventually returned with the correct piece of paper and everything was all right in the end. How much time was wasted in all the to-ing and fro-ing was left to the viewer to calculate.

The NHS is quite possibly the last stronghold of pen and paper left in Britain. Outsiders, unaware of the extent to which antiquated practices are still the norm in supposedly modern hospitals, must have felt their jaws hit the carpet in disbelief at the sight of Graham’s drug round antics. And it wasn’t a lone aberration. In a mere seven episodes – less than three-and-a-half hours television all told – Bedpans and Bandages has presented us with at least two ‘living history’ moments. The other was back in Episode Four, when TK was introduced to a paper prescription sheet that, as his mentor bleakly observed, had as many pages as a magazine. In some houses, I’m guessing that the poor old carpet is taking a bit of a battering.

One question that’s definitely worth asking is whether it’s relevant that both these examples relate to drug round. Considering how much of hospital nurses’ time is taken up by drug round – including IV’s, it can be as much as several hours every shift – it’s a surprisingly low-profile activity. I did it for nearly twenty-five years, but in all that time – despite receiving annual updates on a huge variety of subjects ranging from hand washing technique to fighting fraud – no one once checked to make sure I was still safe. And has anyone ever heard of a pharmacology Clinical Nurse Specialist? I certainly haven’t. Poor old drug round. So much time taken up –  so little attention paid. What’s gone wrong?

In the summer of 2011, drug round was granted a rare moment in the spotlight. In a bid to reduce interruptions and improve safety, a number of UK hospitals introduced red ‘do not disturb’ tabards for nurses to wear while they were administering drugs. Media reaction was swift and furious. The Telegraph, amongst others, reported that ‘patient groups fear it will leave vulnerable people in hospital beds feeling they cannot approach staff for help’ and quoted Joyce Robins, of campaign group Patient Concern, as saying: “If you’re a nurse and you can’t do more than one thing at a time, you’re a pretty hopeless nurse. It sends…completely the wrong message”. Well congratulations, Ms Robins: you don’t do such a bad job of sending out a clear message yourself. In this case, your message is that drug round represents nursing in microcosm – an easy job that any fool could do. Unfortunately, it can seem that sometimes – at least as far as drug round is concerned – employers find it convenient to share your sentiments.

My quarter-century of pushing a drug trolley also coincided with massive developments in pharmacology and the rapid spread of an important new administration route: the PEG tube. But I never had a single formal teaching session on any of this. My colleagues and I were left to educate ourselves; whether we got the right end of the stick or not was left completely to chance. Taken together with the habitual failure to acknowledge the length and complexity of the drug round (as evidenced by unending interruptions from both service-users and colleagues) it’s not surprising that many nurses gain the impression that in the eyes of those who never actually have to do it, drug round is seen as a common-sense low-priority activity that can be fitted around other, more pressing, concerns. But whose are these ‘more pressing concerns’?

From the patients’ point of view, it seems unlikely that receiving the right medication at the right time is not a priority. A contributor to a recent Nursing Times online discussion about whether delays in giving drugs should be counted as errors surely spoke for many when she said ‘It is extremely frustrating to be waiting for analgesia which you know you need to take regularly in order for it to work, only for it to be forgotten entirely or delayed by hours’. Neither is it  only about analgesia – timely medication is absolutely crucial for Parkinson’s patients, for example. And my dad gets noticeably edgy if anything prevents him from taking his warfarin at five-thirty on the dot. Drugs are clearly very important to patients. But if we took more notice of what is actually happening on drug round, could it also help to give a clearer picture of ward stresses overall?

Drug round has remained largely unaltered for decades. The only major changes it has seen are the switch from two-nurse to single-nurse checking, and the (far from universal) replacement of the the trolley with individual patient-specific drug cupboards like the one Graham and Claire were using. So much more could be done – but first, drug round needs to be rescued from the shadows and recognised as the core nursing activity it so plainly is.

Obviously, we need to go paperless. Once we have done this, the scope for safety gains becomes very large. Linking systems to the British National Formulary could eliminate the prescribing of incorrect doses that then take hours to correct and result in avoidable delay (consultants only could be allowed an over-ride in certain circumstances); because the exact time a drug was dispensed/taken would be recorded, it would be impossible to dispense the next dose until a safe interval had elapsed; and shared database would open up the possibility that those patients who wanted to and were able could be responsible for managing their own drugs.

But drug round is also a vast unexplored gold mine of data. Triangulated with other indicators such as staffing numbers and patient acuity, delay in dispensing drugs could be a useful sign that a ward is under pressure. And before readers object that it could also be a stick to beat nurses with (“Nurse, you’re too slow!”), let me add that an electronic system could incorporate a way of indicating that drug round has had to be paused – and for how long and for what reason. Colleagues – including managers – who persistently interrupt and cause delay would have to explain themselves; could there be a stronger signal of the primacy of patient care? More generally, hospitals must start thinking more creatively and open their eyes to the potential of drug round. It has been the Cinderella of nursing for far too long.

For the Telegraph‘s article on red ‘do not disturb’ tabards, see
http://www.telegraph.co.uk/health/healthnews/8728093/Nurses-wear-do-not-disturb-signs-during-drug-rounds.html

For the Nursing Times discussion of whether delayed doses constitute drug errors, see
http://www.nursingtimes.net/opinion/behind-the-rituals/are-omitted-and-delayed-medication-drug-errors/5064478.blog

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