By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

It is with growing concern that MNA has received reports of increasingly ineffective charge nurse utilization in our hospitals.  If you’ve been in nursing for more than a few years, you’ve seen the trend yourself: charge nurses have quickly gone from having no patient assignment, to having a few admits or discharges as needed, to always having half of an assignment, to always having a full assignment… to having two floors?

This alarming new trend is to assign the nurse variously described as a given unit’s “resource,” “foreperson,” and “air-traffic controller” to two units at once. This disastrous model stretches already thin nurse staffing even thinner while eliminating an essential resource for both routine and emergency nursing care. Furthermore, it requires the charge nurse to be in two places at once while making safe, accurate, and timely staff assignments without knowing half the staff being assigning.

When a hospital requires a charge nurse to take on a full patient load, or to be in two places at once, that hospital is putting its bottom line ahead of patient safety. This is dangerous for both the hospital and the charge nurse. In fact,  many experienced nurses are now turning down charge nurse assignments due to their unwillingness to take on the legal risk such unsafe assignments entail.

Charge nurses are essential tools to ensure the right nurse is assigned to the right patient, to help navigate crisis situations, and to ensure care that would otherwise be missed is performed. As one researcher put it, the role of a charge nurse is a “skillful balancing act.” But how can one perform a skillful balancing act on two floors at once?

Is this the end of the charge nurse as we know it? Maybe. It’s up to nurses to stand strong together: do not accept unsafe charge nurse assignments. Do not enable your facility to cut corners and put patients at risk. Do not perform your skillful balancing act with a full patient load on two floors at once. Our patients deserve better.

By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

With Minnesota’s medical cannabis law set to take effect on July 1, Minnesota nurses will likely be asked to administer medical marijuana in the hospital setting.  But are you ready to do so?  Here’s what you need to know about the new law.

• Patients will not receive a medical marijuana “prescription” from a physician or APRN. Instead, a patient’s provider will certify that the patient has a medical condition that qualifies for medical cannabis use.  The patient will then need to register with the Minnesota Department of Health in order to be eligible to utilize the medication.
• Patients will not be able to pick up medical cannabis from the local pharmacy. There are eight locations in the state that are licensed to dispense medical marijuana.
• Patients will not be able to smoke their medical cannabis.  Raw leaf, flowers, and edibles are not allowed under the Minnesota law: only pills, oils, and liquids are allowed.
• Your facility may ask you to administer medical cannabis. Each facility will surely have its own policy and procedure on patients who are admitted and bring their own medical cannabis.  It is possible that your facility may ask the patient to turn the medications over to the hospital pharmacy, which would then ask you to administer the medical cannabis.
• You and  your facility are protected under state law while administering or providing care to someone who is taking medical cannabis.  Minnesota recently passed an amendment to the medical cannabis law.  Per the MN Department of Health:
  

  The amendment extends protections and immunities to employees of health care facilities to possess medical cannabis while carrying out their employment duties. These protections include providing care or distributing medical cannabis to a patient on the Minnesota medical cannabis patient registry who is actively receiving treatment or care at the facility. The amendment also allows health care facilities to reasonably restrict the use of medical cannabis by patients. For example, the facility may choose not [to] store or maintain a patient’s supply of medical cannabis or that use of medical cannabis may be limited to a specific location.

• Federal law still prohibits the distribution and use of medical cannabis. Under federal law, medical cannabis remains a Schedule I drug.  Given state law protections, however, the potential liability and level of concern for individual nurses who are asked to administer medical cannabis per hospital policy should be low.

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By Mathew Keller RN JD, MNA Nurse Practice & Policy Specialist

In a cost-cutting move, many Minnesota hospitals are asking registered nurses to take on more pharmacy duties. Where there may have once been pharmacy staff available 24/7 to answer questions, compound pharmaceuticals, and dispense medications, many nurses are finding that such coverage is now limited to 9-5 with an outsourced pharmacist in another city (or state) available by telephone after hours to answer questions and certify prescriptions. This can lead to potentially dangerous situations for patients as well as nurses’ licenses when nurses are asked to dispense and/or compound medications in the absence of a pharmacist.

One disturbing trend we are tracking is nurses being asked to fill the Pyxis or other automatic dispensing machine on the overnight shift. Non-pharmacy staff filling a Pyxis is unacceptable pharmaceutical practice. Furthermore, it is outside the scope of RN practice.

Under state law, only pharmacists are legally qualified to dispense medications, although they may be assisted in the task by up to two pharmacy technicians at one time.[1] Dispensing is defined as “delivering one or more doses of a drug for subsequent administration to, or use by a patient.”[2] When a nurse fills a Pyxis or other automatic dispensing machine, that nurse is delivering doses of drugs for subsequent administration to a patient.

While nurses may legally administer medications, they may not legally dispense them. Filling a Pyxis is outside the scope of RN practice and can lead to discipline against one’s nursing license as well as charges of practicing pharmacy without a license. In addition to scope and licensure issues, a nurse who fills a Pyxis assumes legal liability for any and all errors or patient harm resulting from improper dispensation (e.g. putting the incorrect medication in a Pyxis drawer).

Another common issue involves nurses being asked to mix IV medications in the absence of pharmacy coverage. The propriety of this practice is situationally dependent: reconstituting medications is acceptable nursing practice; compounding medications is not. Compounding is defined as mixing, packaging, and labeling a drug for an identified individual patient’s use.[3] The determining factor in whether or not you are compounding medications is whether the medication is for immediate use or not.  If a medication is being mixed for immediate use, it is acceptable reconstitution.  If the medication is being mixed for storage and later use, it is unacceptable compounding.

Lastly, many nurses are being given pharmacy access for after-hours care.  Under Minnesota rules[4], after-hours nurse access to the pharmacy should fulfill the following guidelines:

• Withdrawal of medications must be limited to “emergency” situations, interpreted broadly by the Board of Pharmacy to include any time a necessary medication is needed but unavailable;
•  Only one designated RN on a given shift may have emergency access;
• The standard of practice is that narcotic access is limited to a locked narcotic drawer with a small supply of available medications, not full access to the narcotics safe;
• The designated RN must properly document medications removed from the pharmacy;
• The designated RN should have proper training from the pharmacy staff in pharmacy policies and procedures, as well as specific training regarding after-hours access.

MNA has and will continue to work with the Minnesota Board of Pharmacy in order to ensure that our patients are protected through proper pharmaceutical and nursing practice. Have you been asked to fill a Pyxis or compound medications? Please let us know at Mathew.keller@mnnurses.org.

[1] MN Statute §151.01 Subd. 27 (2)
[2] MN Rule 6800.7100
[3] MN Statute §151.01 Subd. 35
[4] MN Rule 6800.7530

By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist

“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”

While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.

As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”[1] 

Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.

Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address.  It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.

As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).

Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors.  How would you change the language to better prevent errors?  Share your thoughts in our comment section below.

[1] Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.

Legislative Update May 8, 2015

Biennial Budget

Ten days to go in this Legislative Session, but lawmakers aren’t much closer on a budget deal than last week. Despite the $1.9 billion surplus, the GOP-led House still wants a tax bill with big cuts for state programs for Minnesota citizens. Speaker Kurt Daudt (R-Crown) said he’s still pushing for $1.1 billion in Health and Human Services cuts.  Big businesses would see their taxes lowered under the GOP plan and even enjoy an end to property taxes.

Working families will have to pay more if the final budget slashes $563 million, as proposed, with the elimination of MinnesotaCare.  Other savings come from shifts and gimmicks. The GOP budget would delay managed care payments by a month to save $135 million and save a claimed $300 million by eliminating ineligible enrollees and working to eliminate waste, fraud, and abuse from public programs. The nonpartisan budget staff reported that this figure is not accurate and even in the best case would save only $16 million by catching fraud.  Meanwhile, the DFL-led Senate is holding to its $341 million increase for Health and Human Services, and the Governor still hopes to increase funds for schools to include all-day pre-school statewide.

The Conference Committee began meeting on Tuesday and continued throughout the week with little progress.  Legislators won’t take much action until their leadership gives them more direction on how much money they need to spend or cut. These new budget targets could come Monday. Legislative leaders, Governor Dayton, Majority Leader Tom Bakk, and Speaker Kurt Daudt plan on fishing together for Walleye Fishing Opener on Saturday. Let’s hope they can “net” a compromise that delivers quality healthcare for all Minnesotans.

MinnesotaCare

This is the insurance program for about 90,000 Minnesotans who make too much money for Medicaid but not enough to buy insurance through an exchange (approximately 134-200 percent of the Federal Poverty Level or about $40,000 for a family of four). GOP lawmakers have placed it on the chopping block because the funding mechanism, the Provider Tax, is set to go away in 2018.  The Legislature, however, has the ability to extend those funds to protect Minnesota’s working class. If they don’t, these recipients will end up transferred to MNsure or another exchange where they’ll have to pay 200-300 percent more for coverage that could pay only 70 percent of their medical costs. As a result, many people who have jobs will end up skipping needed preventive care.  Nurses know patients are coming to hospitals sicker and sicker because the costs of healthcare create barriers to being healthy.
Please let your legislators know nurses care for their patients, and MinnesotaCare allows 90,000 working class families to receive quality care.

Send a letter to legislators through this link.

Nurses Week

Governor Mark Dayton issued a formal proclamation making May 6-12, 2015 Nurses Week in Minnesota.  Legislators in the Minnesota House and Senate issued proclamations in their respective bodies to honor nurses.  Lawmakers also took a moment to stand and applaud nurses visiting the Capitol to honor the vital jobs they perform every day.  Senator John Hoffman (DFL-Champlin) also brought nurses onto the floor after session.

Wednesdays at the Capitol

This week, nurses from MNA’s Governmental Affairs Commission took a trip to the Capitol to talk with legislators. Much like previous weeks, the nurses were well received by their senators and representatives as they shared personal stories about incidents of workplace violence, unsafe staffing and hardships they see facing their patients.  Every Wednesday, small groups of nurses visit the Capitol to meet with legislators about our priority bills. All MNA members are welcome and encouraged.

Nurses in attendance will meet at the MNA office in the morning for a briefing and quick training on how to talk to legislators.  They then carpool to the Capitol to talk to elected officials about the need for Safe Patient Standard and Workplace Violence Prevention legislation.  At around 1 p.m., the group returns to the MNA office for lunch and a debrief of the day.  Please contact Geri Katz geri.katz@mnnurses.org or Eileen Gavin eileen.gavin@mnnurses.org for more information or to sign up.

By Mathew Keller, RN JD, MNA Nurse Policy Specialist

When cuts are made to public insurance programs, we all end up paying more.  Just the other day I heard the story of Mary*, a young woman who found some unusual lumps in her breast.  Having already had her preventive care exam for the year, she could not afford the high cost of following up with her physician.  When she was finally able to get her next annual exam, Mary got the heartwrenching news that she had Stage 4 breast cancer.

MinnesotaCare, a public health insurance program for the working poor, is under threat from state legislators in the House of Representatives. In the long run, gutting MinnesotaCare is a losing proposition for our patients, our hospitals, and our state.

MinnesotaCare is a program for those who earn between 133 percent and 200 percent of the Federal Poverty Line (FPL), which is $11,770 for an individual and $24,250 for a family of four this year. MinnesotaCare currently serves 105,000 individuals and families who work hard and yet don’t have employer-provided insurance and can’t afford coverage on the open market.  The program requires enrollees to pay premiums of $15-$50, depending upon income, and to share in some of the costs of coverage.

If MinnesotaCare is repealed, its current enrollees will be forced to enroll in a private insurance plan, which will cost more and deliver less. For example, a 2015 silver plan would cost an individual earning $16,243 annually a $46 monthly premium, while only covering 70 percent of medical costs. That same individual would pay a monthly premium of $15 while receiving 98 percent coverage under MinnesotaCare. For the working poor, this is a huge difference.

As nurses, we know that the high price of healthcare is often a barrier to the working poor receiving adequate care. According to a Harvard study, unpaid healthcare costs cause more than 60 percent of  bankruptcies in America, and one in five American adults struggle to pay their medical bills.  The rate of unpaid medical bills is even higher among working poor earning between 133 percent to 200 percent of the FPL.

Consider, for example, the price of an emergency appendectomy. Assuming the patient gets to the emergency room before the appendix ruptures, the procedure costs upwards of $20,000. For a working-class individual earning $16,243 annually on a silver-level private insurance plan (with 70 percent coverage), the out-of-pocket cost is still an unmanageable $6,000. When that individual is unable to pay the $6,000, the hospital absorbs the cost under “charitable care,” but the hospital has to raise prices on every other patient to balance the books.  Rather than cut healthcare costs, eliminating MinnesotaCare actually raises costs for all Minnesotans.  It’s a gimmick that budgeters try to make it look like they’re doing a good job.

When individuals and families are afraid to go to the doctor because of what it might cost them in the long run, they put off necessary treatment.  This harms our patients’ health while costing them, the hospital, and all Minnesotans more in the long run. Mary didn’t make it; let’s make sure the 105,000 working-class Minnesotans who use MinnesotaCare don’t need to face the same choices she did.

*Name changed to protect confidentiality

Legislative Update May 1, 2015

House HHS Omnibus Bill
Tuesday night, the House passed its Health and Human Services omnibus bill (HF 1638). The bill includes many of MNA’s issues in various forms:

MinnesotaCare is dropped all together. This is the insurance program for about 90,000 Minnesotans who make too much money for Medicaid but not enough to buy insurance through an exchange (approximately 134-200% of the Federal Poverty Level or about $40,000 for a family of four). Another bill, HF 848, includes tax credits for those dropped from MinnesotaCare to get coverage through the private market or MNsure.  Unfortunately, the proposed credits aren’t nearly enough to provide an equal level of care.  As a result, MinnesotaCare recipients could face high deductibles and co-pays, which could cause them to forego even routine care or just go broke trying to pay for care when they really need it.

CEMT is in the House version, which contains some but not all the language MNA fought for that would prevent Community Emergency Medical Technicians from practicing nursing skills. This bill allows CEMTs to check on and help newly discharged patients.  Because there is a provision in the bill that requires a workgroup to make recommendations to the Legislature on what services will be eligible for reimbursement, MNA will continue to advocate in that workgroup that these services not infringe on the nursing scope of practice.

Temporary license suspension is also in the House HHS Omnibus bill.  This language raises the level of threat a nurse or healthcare worker must pose to patients before that license holder can be suspended without a hearing.

Senate HHS Omnibus bill
Last week, the Senate passed its all-encompassing HHS bill, which includes these MNA issues:

Workplace Violence Prevention Bill
The bill, which would require all Minnesota hospitals to have a workplace violence prevention plan and provide training to workers on an annual basis. Despite a push from nurses and legislators, the data on incidents will only be accessible to collective bargaining representatives and law enforcement.

Healthcare Task Force
This bill echoes the Governor’s proposal to create a task force that will look at other ways to pay for healthcare in Minnesota. This analysis will look at many options.  We hope it will include a study on the savings that could be brought by a Single Payer system. MNA will work to ensure this proposal is in the final budget and to see that nurses are well represented on the task force.

MinnesotaCare
The program continues to operate in this version of the bill, but will face intense pressure and scrutiny as the conference committee decides its fate

Biennial Budget
Two and a half weeks to go in this Legislative Session, and the time to create a budget is growing short. The GOP-led House passed its tax bill Wednesday with a vote along straight party lines. The GOP budget cuts taxes for big business, including eliminating the corporate property tax all together. Those cuts are being marketed as a middle tax class cut, even though a single, $75,000 a year filer would only get $70 back.

To pay for this, the GOP budget underfunds education, and Greater Minnesota doesn’t get broadband, schools, or train safety. In addition, various services offered through HHS would be cut by $1.1 billion.  At a time when we have a $2 billion surplus that could help to move Minnesota forward, their proposed shifts and gimmicks could return us to the deficit days that forced Minnesota to borrow from schools again and again. Stay tuned on the response from the DFL-led Senate and the Governor’s office. It appears this budget won’t be settled until the final hours on May 17.

MNA nurses joined TakeAction Minnesota and many other groups to oppose the elimination of MinnesotaCare in the House HHS budget at a press conference on Tuesday. MNA Executive Director Rose Roach explained the impact of the cuts on Minnesota’s patients.

See clips from the conference here

Rape Kit Inventory
Law enforcement agencies are sitting on hundreds of untested rape kits that could be used to bring suspects to justice. The bill that would look into the status of untested rape kits passed the Senate floor by a unanimous vote.  The bill also passed the House on Tuesday with the same language in the Public Safety Committee’s omnibus bill. There are concerns that some gun-related issues are riding on the omnibus bill, which could tie up this bill as well. The Governor will have trouble signing it with those riders. If that happens, there will be a push to hear the Rape Kit Inventory as a stand-alone bill.

Voter Pre-Registration
The bill that would allow 16-year-old to register to vote before they turn 18 has made it into the Senate Elections omnibus bill but not the House version.
 

Wednesdays at the Capitol

This week, nurses from Children’s Hospitals in St. Paul and Minneapolis teamed up to talk to legislators, and they got a great response from their state representatives and senators. Every Wednesday, we bring small groups of nurses to the Capitol to meet with legislators about our priority bills. All MNA members are welcome.

Nurses in attendance will meet at the MNA office in the morning for a briefing and quick training on how to talk to legislators.  They then carpool to the Capitol to talk to elected officials about the need for Safe Patient Standard and Workplace Violence Prevention legislation. At around 1 p.m., the group returns to the MNA office for lunch and a debrief of the day.  Please contact Geri Katz geri.katz@mnnurses.org or Eileen Gavin eileen.gavin@mnnurses.org for more information or to sign up.

By Carolyn Jorgenson, RN, BSN

As a registered nurse for more than 36 years, I understand first-hand how important it is to reduce unnecessary hospital visits and readmissions. Nurses want nothing more than to take care of their patients and send them back to healthy lives in their own homes. If patients need nursing care in their homes, public health nurses are educated and trained to care for their ongoing medical needs.

Minnesota RNs have concerns about a proposal in the Legislature that could have serious impacts on patients who have just returned home from the hospital and need more care.

Senate File 176 would give emergency medical technicians authority to perform some of the care that nurses provide to patients recently released from hospitals.

RNs value and support the important work EMTs perform. They are a critical part of our healthcare system.

However, the bill in the Legislature could put patients in jeopardy.

I have been a hospital RN, a public health nurse, and a women’s health care nurse practitioner. I  was required to have a Bachelor’s degree in nursing in order to even be certified as a public health nurse in Minnesota and get a job in that field.

RNs receive at least 1700 hours of learning while earning their degree. Approved courses for EMTs generally require 120 hours.

EMTs and paramedics are very knowledgeable about emergency treatment and emergency medicines. But do they know about medication and treatment for chronic diseases? I took a whole semester’s course in order to learn pharmacology and I continue to learn new medication information daily. (Yes, even after 36-plus years)!

So, if an EMT goes to visit a patient who has recently been discharged from the hospital, and the patient states they are “taking the pink pill but not the blue pill,” an EMT may not  know what every drug is used for and how they all relate to that patient’s condition and how the different medications interact.

I realize they say the EMTs will be “providing treatment under the medical director’s license,” but I would never believe an ambulance service medical director would be available 24/7 to do a medication review on every patient!

My concerns stem from my dedication – and all nurses’ dedication – to our patients and to see they get the care they deserve, and for which our great state has earned a reputation as a leader in healthcare. When supporters of the bill say they’re concerned about the rising costs of healthcare, I say, “What is a life worth? What is a person’s health worth?”

If hospitals really want to help our discharged patients, they should send highly trained and educated nurses to patients’ homes for follow-up. This would save millions of dollars by preventing readmissions. I don’t believe this bill as written is going to help our residents.

How far have we really come the since 1911, when the Triangle shirtwaist factory fire killed 146 people, most of them immigrant women, nearly half still in their teens? This film was commissioned by the National Consumers League and the planning Committee for the Washington DC Triangle Shirtwaist Factory Fire 100th Anniversary symposium.