This is a true story. When I first got out of nursing school, I was given the assignment of passing meds and doing treatments for 25 residents in a long-term care facility. I walked in the room and a sweet little lady was sitting in a rocker next to the bed. “Mrs. Black,” I asked? She replied,” yes” so I prepared and gave her meds. About that time a CNA walked in and said, “Mrs. White, let’s get you back to your room.” Well, you can imagine my horror.
The resident had wandered into the room and sat in Mrs. Black’s chair. Mrs. Black was actually in the dining room eating her breakfast. Can you imagine the horror I went through? I just knew they were going to revoke my hard earned nurses license, I was going to jail, and Mrs. White was going to die from the wrong meds. Luckily, it was a multivitamin and a stool softener. My point is, with paper there is no black and white. There are only a lot of gray areas, errors being made, meds being missed or given to the wrong person, PRN’s not being followed up on, allergies missed. As for treatments, wound assessments were done on Thursdays, so anything discovered during the week was missed or buried in a nurse’s paper notes. No accuracy, time consuming, always done after the fact at the end of the day or week.
Fast-Forward to Automated eMAR & eTAR
My picture of Mrs. Black now shows up right on my eMAR along with her allergies, so there is no room for error. Missed a med? When I attempt to move on to the next resident I receive an alert that says, hey, you still have one more med to give. Are you sure you want to exit this resident? My diabetics are highlighted, so if I want to make sure these folks get their sliding scale insulin first, I know exactly who my diabetics are. If I’m giving a PRN pain medication, I can document an entire pain assessment, right there, at the point-of-care. I’ll also get an alert both in my eMAR and on my ECC dashboard that I need to follow up and chart my results – and I do that immediately, right at the point-of-care.
My med pass can now be completed timely and efficiently with a huge reduction in error in less than half the time. With regard to treatments, if I am for instance, treating a stage 3 pressure ulcer and I see a change, I can do a complete skin and wound assessment immediately, right at the point-of-care, not at the end of the day! The bottom line is fewer errors and higher reimbursement because nothing is forgotten or buried under a mound of paper. There’s more time to spend with the resident and built-in documentation with complete accountability allows for peace of mind and for nurses to be nurses again.