Nursing: Managing Technology

Broken Promises…or 
Wasted Efficiencies?

Breakdowns, antiquated policies and other factors that influence technology utilization.

By Leah Curtin, RN, ScD(h), FAAN And Roy Simpson, RN, C, FNAP, FAAN

Humorist Sam Levenson once remarked that everything today "depends on automation which depends on computers which depend on electricity which depends on machines which depend on computers, which depend on electricity…Man, who has gone from absolute to obsolete, is recalled only in case of a breakdown of the machines which have made a tool of him."

Indeed, computers have invaded just about every aspect of time and work – and keeping them working has become one of our more important (and often most frustrating) functions! Let me share some thoughts about the "breakdowns" with which many of us are all too intimately acquainted.

For our first challenge, consider the problems under the generic heading of "promises made and promises broken." Many are the people who fail to make optimal use of the technologies for which their employers have paid handsomely — and many are the promised savings that are not realized because the technology is underutilized. Is the problem with a sales staff that exaggerated the machine’s capabilities, or with an environment that does not support optimal performance? That depends, of course, on a number of factors, but more often than not, the real problem is one of wasted efficiencies rather than "broken promises!"

Consider the problems that often surface when one is introducing a new technology like the use of drug dispensing machines (DDMs). While these machines effectively control inventory, reduce theft, and capture costs, they are not "islands unto themselves." When the drug is dispensed to the nurse, it is automatically charged (date, time and cost) to the patient’s account – and, in fully integrated systems, recorded (date, time and amount) on the patient’s e-chart — along with the identity of the nurse to whom the machine dispensed the drug.

Ideally, that would be that. However, in the real world of antiquated policies, scaled down inservices, and nurse-patient ratios that range from 4 to 14, the drug may or may not be given by the person designated at or around the time recorded by the drug dispensing machine.

Questions Raised

This raises both questions and "hackles" as various and sundry individuals try to interpret "the law," object because "my license is on the line," and seek help from policy and procedure manuals to no avail! This situation arises for several reasons:

The nurse may enter a patient’s room to administer a drug only to learn that the patient is allergic to the drug, is not in his or her room, or refuses to take the drug. Moreover, the nurse may obtain the drug fully intending to administer it promptly, and be delayed by a patient emergency, a physician’s request or any number of unforeseen obstacles.

Under the old system of documentation, the nurse knew how to handle the problems because, for one thing, the medication was not charged or documented as "given" yet, so the nurse merely noted a change in the time of administration, notified the physician, etc. Now, with the advent of the DDM, the medication is already charged to the patient and even documented as given! What to do?

Many an institution, in the midst of cost saving frenzies, have scaled down inservices to almost nothing — and thus have not inserviced the staff (or, at any rate, all of the potential users such as part-timers, travel nurses, etc.) to the DDM’s process for additions, corrections and deletions from the system. Thus, rather than saving time, the nurse may spend an inordinate amount of time looking for someone who knows how to alter the DDM’s documentation. This is not efficient!

To exacerbate the matter, many institutions that invest in technology refuse to invest the time and money needed to rethink and revamp their policies and procedures to accommodate automation (in this case, in regard to the dispensing and administration of drugs). The "old" policies are in effect until new policies are in place, which makes nurses very nervous (if they look them up) about their liability and/or their licenses if they depart from the established routines. This is not only efficient, it is unnerving, and may cause no end of unfounded worries and problems.

Nurse practice acts in most states merely authorize nurses to administer drugs, but are silent about the processes and procedures the nurse is to use to administer a drug. Presumably, the lawmakers believe that institutional policies and procedures will fill this gap, and nursing staff often think that "the law" requires them to follow established procedures which cannot be changed because the law doesn’t permit it – which rarely is the case.

The patient’s chart (e-chart or otherwise) is a legal document that can, and occasionally is, called into court, audited by payers, regulators and others. It also happens to be a major mode of communication among caregivers (its original and intended purpose)– and the nurses are right to be concerned about its accuracy for the sake of the patient, themselves, and their employers.

Re-engineering Problem

To use current jargon, what we have here is a re-engineering problem. Even the most advanced technologies in the world depend on human operators who function within a defined framework of policies and procedures without which they (the humans) become increasingly insecure. Re-engineering for new technology requires at a minimum that one allocates time and money for the learning curve, re-engineers function(s) to fit the demands of the technology and their associated policies and procedures, and prepares staff for these changes through inservice education and, where appropriate, the use of outside expertise.

In the world of the not too distant future, the drug-dispensing machine will be linked to the nurses’ voice activated pocket computer. The DDM will record the date, time and amount of drug dispensed and to whom, and the nurse will activate both the charging and recording functions when she or he actually administers the drug. However, there still is the world of today with which to cope.

It is by no means beyond our technical capabilities to reprogram the DDM to record only the date and time and persons to whom and for whom the drug was dispensed. That’s what DDMs did before integrated systems. Linking the DDM to each nurses' pocket computer is not a viable option if for no other reason than they usually don’t have one. Few (if any) institutions provide nurses with a Personal Digital Assistant (PDA) or their clinical equivalents. Thus, from a practical standpoint, we must look to other solutions.

DDMs are essentially glorified vending machines (although the time-honored practice of banging them or kicking them on the side works even less often with DDMs than with soda and candy vending machines. They can be programmed for many uses such as allocating linens in the OR, dispensing patient care products on patient units, and of course, the DDM itself can be modified to dispense syringes, IV tubing and other drug related paraphernalia.

None of which will do much good in the long run if people are not taught to use the DDM properly, and procedures are not modified to accommodate the machine. It seems so simple, and perhaps it is — most people miss the obvious.

Dis-integrate?

In the event of a full-blown neurosis occasioned by antiquated policies and poor-to-no-inservicing complicated by misinformation and speculation, the most likely thing to happen, at least as an interim measure, is for IT to be asked to dis-integrate the DDM’s integrative function. This has the unfortunate affect of dissolving any savings in time or money that may have been realized by the purchase of an integrated DDM. Fortunately, this is entirely unnecessary if time is taken to rewrite the institution’s policies, procedures and nursing standards in regard to the dispensing and administration of drugs.

Some institutions will call in consultants to fix the machine when what they need to do is re-evaluate how they introduce technology into the practice environment. It is most unfortunate that re-engineering has become synonymous with slashing FTEs when, in actuality, it is a process crucial to incorporating new knowledge and new technologies.

In the case of DDMs, policy changes that accommodate automation must include defining the procedure for charging for medication administration by educating nurses about charging at distribution, charging at return of inventory count, charging at the point of administration, charging at the point of documentation, and charging at the point of labeling and compounding.

Along the same lines, unless time is devoted to staff inservices about how to record corrections in the DDM’s automated documentation system, documentation errors and lost or erroneous charges will increase (or at any rate, won’t decrease) and any time savings assuredly will be lost. You see the point about re-engineering?

Some institutions, finding that fully integrated systems have "too many bugs in them," are backing away from full implementation until they have been de-bugged, when the "bugs" are usually in the old system they failed to re-engineer, and in the ingrained habits of people who "have always done it this way" for so long that they actually believe that doing it their way is the law! Thus appropriate outsiders to bring in may well be both a practice specialist from the state board of nursing and the institution’s legal counsel— anyone who can credibly and authoritatively explain what the state nurse practice act does and does not require and answer questions.

Drug dispensing machines really can deliver on their promise —if you’ll let them!

Leah Curtin is editor-in-chief of Metier Publications, Cincinnati, OH. Roy Simpson is vice president of McKessonHBOC, Atlanta, GA.