Monday, April 23, 2012

For the past 30 years our Heparin infusions have been measured in "units per hour". Recently, this has been changed to a weight based method of prescribing, and it all seems to be tied to the "Anti-XA" method of measuring something, to quantify the anti-clotting effect. But really, the drug didn't change, the purpose of infusion did not change, the adjustment protocols changed a bit (and are far more convoluted and confusing, from a Nurses perspective), and to my simple attention, this is all bad.

Lab Scientists and probably the ISMP and JCAH, all think this has to be "simplifying"...........whereas, in our practice as "those who must follow the Protocol", this new methodology is totally FUBAR. It is mucked up, bucked up, totally frickin' crazy.

There was no good reason to switch the dosing from "units per hour" to this new-fangled stuff. And thus, I guarantee, there will be more mistakes.

The Felicity of Complexity

Listen to the Engineers
They ought to know,
Make a process more complicated
New problems will show,
It's the nature of those men
And the machines they will build,
They don't do simplicity
In the Complexity Guild.

When you're looking for safety
In the delivery of medication,
Don't increase the complexity
And then describe with obfuscation,
Because, you must surely consider
The audience you serve,
If you have 12 different lingo's
Complexity will throw a curve.

Take Heparin, for example
It was dosed units-per-hour,
Now there is a weight based formula
But it still has Heparin's power,
The drug didn't change
Only the method of defining,
It went from simple to complex
And that's why I'm whining.

The dosing nomagram
Is super confusing,
Preprinted for Nurses
By a Doctor's order, for infusing,
And although it's his duty
To deal with this stuff,
We are supposed to make adjustments
Which is more than enough.

While the recipient can't tell
That units-per-kilogram-per-hour,
Is like electricity from the wind
How it's different from solar power,
Which, forces the question
Why change the method, how we dose,
Complexity drives mistakes
Eureka!, I diagnose.


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