Record Holder

It has been said that Craig is Chartwell Home Health Service's record holder for having the most medications (IV mostly) distributed to an "in-home" setting. It takes them the better part of the day to mix Craig's TPN and prepare his various IV meds. Folks requiring his level of care are usually in the hospital, so says the home-health nurse who checks in on Craig every week. Each time they deliver the boxes (plural) of medical supplies, I "ham it up" in tribute to the moms with a lame "I feel like the president, signing my name so often" comment--yuk yuk yuk. One delivery gentleman in particular said Craig beat others by a long shot in terms of how many sheets we have to sign, and medications that are "inventoried". In an arrogant/sarcastic fashion, I quickly replied, "well, there are no losers in our family and we want to make doubly sure no one can catch up". Hey, I charm the delivery fellas, what can I say.

All those who attend to Craig in a legitimate healthcare capacity often boast of our--perhaps illegitimate--nursing talents. Even the pharmacist kept me on the phone in the wee hours of the morning to profess the pharmacy's astonishment and appreciation for "what you [Diane, Jill, Emily and I] are doing". Yet, as we know, even the most skilled nurse can make mistakes. Ech hem, it takes a bit of humility to admit to succumbing to the human factors "set-up" of one of Craig's medications. I'll preface this by saying in my best 9 year old tattle-tale voice--Jill did it too. ;0) So, there!

When Jill trained me, she pulled out one of the many pre-filled syringes for Craig's IV meds. The Benadryl, as it would turn out, had TWICE the dose that was to be actually administered to Craig. Stupid say what? I told Jill this was a textbook "Human Factors 101" issue. The chance (and likelihood) of giving the full dose was extremely high--particularly under stressed conditions such as ours. Great! Just my luck...watch the human factors person who works in patient safety overdose her brother... Not so great for my street cred.

Six AM rolled around for my very first shift after Craig's discharge. I popped out of bed determined (and perhaps nervous) not to make a mistake (HF problem number 1: stress and horrible working hours, which cause fatigue, can affect 'vigilance'. More reason not to SET PEOPLE UP through poor design). I prepared the meds, stood bedside, and confidently (though sleepily) pushed one med after another. It wasn't until after I pushed the full syringe of Benadryl that I realized my error (HF problem number 2: it should be a single dose syringe to avoid such easy errors!). By the way, they are all in identical syringes save that for the occasional size difference. The only distinguishing characteristic is a faint, dot-matrix type printed label. Brilliant. Who can name the other human factors issues (plural) here?

I texted Jill to report the issue. After all, there's no learning in avoidance. She said, "don't worry. I did that too my first day. That's actually his real dose; he just PREFERS a smaller dose". Thank the lord for small favors, right! No harm, no foul. WOW. But, it's interesting when you can identify a train wreck waiting to happen and there's nothing you can do to avoid it. I couldn't really waste the Benadryl without compromising sterility. To rely on the always helpful advice like "try harder" and "really pay attention this time" is about as useful as Paris Hilton is to acting (or singing--you pick). Perhaps "more training", "work direction", and "education" would have been of use. Or maybe, WE COULD HAVE THE RIGHT DOSE IN THE SYRINGE! Goes to show how certain situations set you up to fail, despite your best intentions. Such is the case for Mom when navigating wheelchairs on sidewalks and through restaurants, bathrooms and the like. The physical environment does not support wheel-chaired patrons....still. It sets one up for a certain amount of failure in the sense of not achieving goals peacefully, effectively, and safely.  

To my surprise, the next med drop-off had single dose syringes and we haven't had a repeat event since. Imagine...  It's amazing (hands in the air) what thoughtful design can do...