MD refuses to sign a telephone order. - page 2

I'm a new grad working on my own for almost a month now, starting in ICU at a hospital where the acuity of the patients is rather low, so I consider it a SICU. I had a pt with a history of cvs with... Read More

  1. 7
    The communication between you and the MD was too casual regarding heparin. Heparin is a dangerous drug, and it's D/C in such a high risk patient should have sent up a red flag. Sudden D/C of heparin without Coumadin coverage seems like an emergent response to an adverse reaction, such as HIT. Also, if you had known a HIT test had been done, though the results were pending, this should have sent up another red flag. HIT testing is done in response to a suspected problem, and administering lovenox when you knew the possibility of heparin induced thrombocytopenia existed- as lovenox is a low molecular weight heparin- was careless. You were just following orders and you are human, but nurses must be vigilant and question orders at times. The MD ignored the same red flags you did, or failed to investigate the patients' case ( sudden heparin D/C, no coumadin overlap, overweight CVA client=???----> HIT test pending) The MD may not have remembered the conversation he had with you, and knew that he would have never knowingly ordered lovenox for someone with HIT. He may be lying, confused, forgetful, heck he may also be inexperienced. Pointing fingers wont protect the patients or fix the problem in the future, but begin to recognize high profile medications like heparin or insulin with reverence- and a touch of fear. No matter what medications you patients are on, be vigilant, and do your homework before calling the MD, look at labs, history, vitals, really stick to SBAR- and use critical thinking so you can protect yourself and your patients. You did a good job advocating for your patient who was at such high risk for DVT but the patient was put in more danger for DVT in reality (HIT ironically increases clients chances of clots); Doctors are humans too, believe it or not ;] hang in there, with experience the process will become easier. Remember the themes we learn in nursing school- collaboration, accountability, advocacy and competence. Good luck!

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  2. 1
    Pharmacy should have been aware of the hit order too. The doc is being less than honorable.
    Liddle Noodnik likes this.
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    Thank u everyone for your feedback. I will need to stick to sbar better and do my he more before calling the dr. I hope this comes easier with experience. Also I liked how a lot of u suggested getting another nurse to verify the order so I have backup, at least with this particular dr.
    GHGoonette and jalyc RN like this.
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    Quote from aknottedyarn
    I do not know what it is, a test? a diagnosis?
    HIT= Heparin Induced Thrombocytopenia

    If HIT is suspected, a blood sample can be sent to lab to confirm or rule it out.

    OP-- A pending HIT test should be passed on in report. If not, you should have seen the order as you reviewed the chart with the off going nurse, or during your 12 hour chart check (something I always do at the very beginning of my shift).

    As a critical care nurse, you need to know your patients lab values too. This is something else I check at the very beginning of my shift, right after report. If I have two patients, I can do this in less than 15 minutes. If I have an inevitable emergency at change of shift, this is something I make a priority to do once everything settles down again. I consider it a part of how I keep a patient safe (what if the physician missed the K+ of 2.5 and by you looking, you can alert them?).

    Also, a + HIT should be a critical value that the lab should call and verbally report to the nurse as well. Does your hospital do that?

    It's hard to be new in the ICU! Hang in there!!
  5. 0
    Thanks, every once in a while the abbreviations don't click.
  6. 3
    Totally agree with cstrazis! We also post a sign above the bed or on the ICU glass door that a HIT lab test is pending . This serves as an extra alert so no one decides to order any heparin and all heparin flushes are held until results have been obtained. One thing too that may have tipped you off to a lab test pending or a problem is to check the patient's platelet count. The MD probably saw it decreasing and ordered the lab test.Also immediately list heparin as an allergy if the test comes back positive.

    Now as far as the MD goes I suspect they were not aware of the test result pending either and now cannot take ownership of the order. I am of course not certain of this but I would have a high degree of suspicion. This is a great example of how critical the nurse really is because if you would have been able to piece the puzzle together you probably would not even have called the MD.

    On high alert mediciations I too would get a second nurse on the line if a telephone order must be taken.
    jalyc RN, Orange Tree, and Seasoned like this.
  7. 1
    Even if you didn't know about the HIT test, always check platelet counts before giving lovenox.
    turnforthenurseRN likes this.
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    Ya this has happend to me a number of times. However I have never viewed it as MY problem. It's managment's (nursing and physician) problem. Obviously you wrote the order as "T.O Dr.Liesaboutorders". The last time my nurse manager called me about an unsigned order and asked me if I was sure about the order I had recieved. I said "yes, now good luck with that, bye bye".
    One hospital I worked at we had a doc who would refuse to sign tephone orders occasionaly. After this happend to several nurses we all got together and agreed that none of us would accept phone orders from him again. That meansd he had to come in so many times that he ended up just sleeping in the hospital when he was on call. This made his life so miserable that he quit. Man was he mad! He used to threaten us with being fired (our NM laughed at him) and all sorts of other things.
    You need to remember this particular physician is a person with low integrity and NEVER take another phone order from her again.
    Last edit by IndiCRNA on Dec 25, '12
    Nurserton, wildboo, jalyc RN, and 3 others like this.
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    "I told her to check the phone records and see if that particular MD called on the date and time tht I charted her telephone order. She said she can check to see who was on call tht day. I JUST got my license a few months ago, and I'm shaking at the thought of loosing it over a matter of her word against mine. When r they going to start recording every phone call so ths doesn't happen. I am so angry and I wanted to know what I could do to prevent this from happening again, if anything."

    It has happened to all nurses at least once. But to smart nurses only once!

    It is really important that you have CYA game plans to protect your license. So it is very good you are reaching out to collect suggestions! For MD orders at places that do not have electronic records your back-up is your colleague, charge nurse, or nurse supervisor as a witness. For every MD verbal order? YES!

    The practice of verbal orders are outdated, keeping nurses at the mercy of physician negative politics. Only the progressive electronic record systems will save a nurse from a verbal order dispute.

    Get in the habit to TELL ANOTHER NURSE for every verbal order and put her name in your progress note, e.g., "In consultation with Betty W. RN.... or I mentioned my suggestion of_______to Nurse BW who witnessed my getting a verbal order from Dr. Con at 2300." Word it anyway you iike. Just write the narrative ASAP after documenting the exact time with your witness that the order was said.
    Nurserton and Enthused RN like this.
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    The use of phone orders is one with many errors. Be sure to document the readback of the order to the physician and they confirm. Very soon all orders will be electronic and the responsible doctor will be typing what they want leaving no room for the denial who wrote what.
    Last edit by riggy3 on Dec 26, '12 : Reason: spell
    aknottedyarn and jalyc RN like this.

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