Prepared by Patricia A. Patrician, Grant T. Savage, and Eric S. Williams (2017)
“Darn! I have to call Pharmacy again,” Lisa, a staff nurse on 6 East, muttered under her breath. “This is the third time today and it’s not even noon!” she left the Omni-Cell Cart in the medication room and proceeded to the phone at the nurses’ station. She dialed the familiar number – she had it memorized of course – and thought, ” There has to be a better way.” For the past few days, she had noticed an increase in the number of medications missing form the medication carts. Two days in a row, she was able to get a vitamin from another patient’s medication drawer and administer it to her patient, but she knew this did not solve the problem. She was just trying to make it through her shift and get the patients what they needed.
In the meantime, on 6 West across the hall, Deirdre had a similar issue. The morning dose of her patient’s oral antibiotic was not in the drawer, she she gave the dose that was labeled “evening dose”. The evening shift nurse then had no evening antibiotic dose in the drawer and had to call the pharmacy to get a replacement. Numerous calls were being placed to the pharmacy. The pharmacy technicians were so busy fielding phone calls that none of them were available to deliver medications, so that staff nurses had to leave their units and patients and go to the pharmacy in the basement to retrieve their missing doses. The pharmacy technicians began complaining to their supervisors that those 6th floor nurses call so frequently that they do not have time to do their work. Nurses complained to each other that pharmacy was not stocking the medication carts correctly.
Students must discuss the following question:
In an organization that espouses a good patient safety culture, what should happen next?
