Sliding Down the Emergency Chute into the Rubber Room

Insanity is doing the same thing over and over again, expecting different results.

Albert Einstein

The health care industry likes to compare itself to the airline industry on issues of reporting safety concerns and quality control. In a weird way, there is a parallel comparison between flight attendant Steven Slater’s dramatic exit from a jet last week and nursing. While the media and lawyers discuss Slater’s actions, I find myself wondering which daily, routine complaint about nursing is the one that could make me grab a couple of pudding cups out of the patient nutrition fridge and run screaming “I quit” through a fire exit during a hospital fire drill? Maybe I should have a few head shot photographs on hand for the media if it happens. You want a reality nurse show? I’m your girl.

A pilot told me the most common reason a flight is delayed for take off is because someone forgot to order ice for the beverage cart. It takes fifteen to twenty minutes to correct the oversight. The most common reason patient care is delayed in a clinical setting is a lack of physician orders.

Physician’s (or Nurse Practitioner’s) orders are the foundation of bedside nurse practice. Even with a patient sitting in front of you, demanding care, a nurse can do very little without a clearly written, dated, signed order with two patient identifiers (name and date of birth).  These precise rules of communication are safeguards of patient safety. Enforcing them does not reflect obstinacy on the part of the nurse. Because of this, trauma centers and high acuity areas like intensive care have protocols and collaborative practice order sets so nurses can start treatment in the absence of a physician, should crisis occur.

The patient with an appointment at an infusion clinic is usually not in crisis. The most common reason their appointment is delayed is the lack of physician’s orders. Often, there is an order, but it has the wrong date. Or there isn’t a patient’s name on it. Or the dose, or licensed practitioner’s signature was omitted. Or the MD’s office receptionist, who isn’t licensed, signed it. The variables are endless. When I pick up a chart and find an incomplete order, I call the doctor’s office for a legal order so that the appointment doesn’t have to be rescheduled, but there’s usually a delay. Physicians are as busy as nurses. If they are on, they are with patients, either in the office or at the hospital. Or they’re in their car somewhere between the office and the hospital (the era of them being on the golf course is long gone since before I was a nurse).

Lots of things have changed during my twenty+ years of nursing, but what constitutes a valid doctor’s order has not. We’re all human, and busy, and things get missed. Some doctors have software on their office computer that prompts them to write a complete order, and provides an electronic signature. This way, their office staff can pull it up and fax it to the clinic without interrupting the physician when they’re called for unsent or misplaced orders. Many hospitals are converting to physician computer order entry to prevent treatment delays and errors. However, most urban physicians admit patients to multiple hospitals, and this solution requires them to learn multiple computer programs. Understandably, many are resistant to do so.

And this is the quandary: Hospitals and infusion clinics depend on physicians to admit patients to them. Keeping them happy is a part of customer service. So, hospitals and infusion clinics are reluctant to mandate physician computer order entry. However, this creates another customer service problem: the delay or rescheduling of a patient’s treatment, resulting in unhappy patients who may choose to go elsewhere for services.

Sometimes when I phone a physician for orders after the patient has arrived for their appointment, he or she will say, “My office faxed those orders three days ago. Why am I getting called on the day of the appointment to fix my orders?” That is a very good question, and it’s the one that makes me feel like I’m taking crazy pills. How does a patient get an appointment scheduled if they don’t have valid orders, or any orders at all?

Someone forgot to order ice for the beverage cart. Someone forgot to look over the orders when they came through the fax machine.

People are human and mistakes happen. When the same problem occurs frequently, over and over again, something is wrong. There are many factors in health care beyond the control of physicians, nurses, and management, so that when there are factors that can be controlled, we should do so.

Before someone grabs a couple of beers and slides down the emergency chute.