Sloppiness results in write-up

[longjourneydream]

Hell again,

If you have read my previous posts, I am a new grad in the ER since June of this year.

Yesterday I was called to my directors office, because one of the Docs had written me up.

Now that I look back on it I was being sloppy.

The patient was a chest pain, but not cardiac in nature.

Phlebo automatically went in drew labs and sent them, they were ordered by triage out front so they had been done.

I did not do an IV because in the past we give can give meds IM, and her EKG was fine and she had no cardiac hx.

Later Dr. gave me a verbal to give Toradol 30 mg, without asking the doctor the route I went to accu-dose drew up 30 mg Toradol and gave it IM, this is what we have done in the past.

He asked me if I gave the Toradol and I said yes I gave it IM, he said ,"Why does this patient not have an IV she is a chest pain?"

He said now the dose is now doubled due to it being IM it will be an

additional 30mg.

I told him it did not seem to be cardiac in nature.

He yelled and said it is either worked up as cardiac or non cardiac no exceptions! You need to know the difference.

Later I had done a triage for another nurse because she was busy.

I had failed to put in vitals, as well as spelled some of the meds wrong.

As a result the wrong route and incomplete triage was turned in to my supervisor and director and now I am on probation for 60 days. with weekly progress notes from my preceptor.

NOW,

I had asked for more time in the ER after my 12 weeks, because I was falling apart.

They have been putting me with seasoned nurses, to help me when I need it, but still have to carry a full load, but I do get help from the unit and the charge nurse.

The new plan is to have me precept with a 40+ year vet, and she is to help me with time managment, but because of being written up, I am to review all meds with her, and she is to check all my triage notes.

I am to do this for 60 days, it is a probationary period.

WHAT A LESSON!!!

I FEEL AWFUL...

I have worked with this nurse last leason and she is awsome, and is always there to help anyone in need.

They told me they are doing this to protect me.

Well I know I should have reviewed the medication route with the Dr.

That was a big mistake, and yes I will learn and never assume, and clarify with the Dr. 1st.

I do not blame the Dr. because he does not want his patients in danger, and he is also the ER director, so he has plenty of pull.

I know I can turn this into positive experience.

The Dr. has been super nice to me lately since my write up and he explains everything to me to help me with my learning experience.

Now there is no room for sloppyness, I am now under a microscope.

Any input from anyone??? :uhoh21:

[Noryn]

Noryn,

Why would you advice someone to quit after one hard shift? And to go from ED to ICU because going to ED as a new grad is hard, well in my opinion going into ICU as a new grad is even more challenging! There were lessons to be learned here and should not be overlooked, giving the medication using the 5 rights, assuring an access (IV) for emergency situation, spelling medications correctly and time management. and it seems that cweeks has identified and learned from her experience and will continue to learn and do well. Cweeks- dont quit hang in there, it gets better!

"So in the future remember the more you do, the more you get in trouble for." - I disagree, we should all be helping one another as a team.

It goes beyond one hard shift, generally these posts are vague (for a good reason to avoid identifying workers) but I feel the original poster is being disrespected and working in a poor environment. Being on "probation", that isnt supportive, that is demeaning and breaks your confidence. They should be supporting their new graduates for at least the first year. These situations are not entirely on the OP. As I said before the doctor should have specified what route. Doctors are not allowed to run around and yell incomplete orders. The OP also forgot to put vital signs in a computer, now that is ridiculous, we are all humans and entitled to make mistakes. Not too mention that the OP was helping the triage nurse.

The medical director which is the doctor should share responsibility in the mistaken. There is a failure in that system so fix the system, dont blame it on the nurse. If they are going to give verbal orders then they need to be complete.

Giving Toradol for non cardiac chest pain is not an emergency. So I am still in the dark about why that patient had to have an IV.

The point about the more you do, the more you get in trouble for is sad but true. I dont agree with it but I bet you will find that most nurses agree.

So now that Cweeks is on probation what happens if she makes another mistake?

[dorselm]

Cweeks,

I like the fact that you admitted to your mistakes and were willing to learn from them and hang in there. I think you are going to very a very good ER nurse and wish you all the best!

[ebear, BSN, RN]

Noryn,

I don't quite know why, but I'm losing your rationale. Maybe I'm just a doofus....So, you're looking at this as a "punishment"? IMO, they are trying to help cweeks by extending her orientation and assisting her in developing the skills needed to work in the ER. The IV is dependent upon her hospital's policy concerning chest pain protocol. We were not given that info. The Torodol issue should have been questioned. Doc should have stated route and she should have questioned him prior to assuming IM (or any other route) She should stay in the ER since they are willing to work with her and I'm sure she will be a very good nurse, as she apparently takes constructive criticism well.

ebear

[nyapa, RN]

I would honestly quit,

Don't quit! From what I see you have written, everyone is generally happy with you, and they are willing to support you. They obviously want you, or they wouldn't be putting in all this time and effort. You are valued.

"go forth and prosper"

(((Hugs)))

[Noryn]

Noryn,

I don't quite know why, but I'm losing your rationale. Maybe I'm just a doofus....So, you're looking at this as a "punishment"? IMO, they are trying to help cweeks by extending her orientation and assisting her in developing the skills needed to work in the ER. The IV is dependent upon her hospital's policy concerning chest pain protocol. We were not given that info. The Torodol issue should have been questioned. Doc should have stated route and she should have questioned him prior to assuming IM (or any other route) She should stay in the ER since they are willing to work with her and I'm sure she will be a very good nurse, as she apparently takes constructive criticism well.

ebear

It is just my opinion, I am not always right. From what I read in the post it seems like a poor learning environment. Whenever a doctor writes you up generally that is written documentation that goes into your employment file. It was non cardiac pain, but if the MD wanted an IV why not just pull the nurse aside and say, "Hey, the hospital is pretty strict about following protocol, always put an IV in." Instead per the original post "He yelled and said it is either worked up as cardiac or non cardiac no exceptions! You need to know the difference." Yelling solves nothing, except demeans or berates someone.

I am sure the original poster is already a great nurse. I just think she is being treated poorly as many nurses are. My concern is that she is officially being placed on probation hence the paper trail is starting.

Again if it were me, I would talk to the doctor and nurse manager, explain that I think they handled it incorrectly and give my rationale. I would be very respectful, if I liked the job I would tell them that I really wanted to be a nurse there. But I would not accept probation status over this.

[ebear, BSN, RN]

"...but I would not accept probation status over this..."

Well then, you could kiss your glutes goodbye.

[Noryn]

"...but I would not accept probation status over this..."

Well then, you could kiss your glutes goodbye.

Wouldnt be the first time . And I would take my self respect with me.

[ebear, BSN, RN]

Happy trails!!

[steelcityrn, RN]

Yes, I agree with most of the others. Does seem like a very fair place to work. Its good that you will be with a nurse who has worked there that long and you get along with well. Its a shame that we have to clarify so many orders from physicians though. Nurses can do many things, but mind reading we are probably average at.

[TRAMA1RN]

I am going to appologize before writing my reply. This is why I feel that serious consideration be used before hiring new grads in ER. Part of knowing what is cardiac and what is not comes only from experience, which I feel is best gained by getting med surge experience first. This also help with time management skills. Unfortunately now the seasoned nurse is yet again going to have more work for herself. I am sorry that you did not get your orientation of fellowship time extended, but in the ER you need to be able to get up and go. Time management is essential. Most people today that come in ER with chest pain complaints even if they seem benign will end up getting cardiac workup. The ER's I have worked all state any chest pain comes straight back and gets EKG. So you might as well do IV and blood draw immediately as well. Even and EKG that looks normal can be early MI. PAtient's immediate history and family history all are taken into consideration, drug abuse history and smoking histaory as well as other health considerations need to be considered. I am sorry there is no excuse for missed vitals on a patient. To think that you are now under 60 days close supervision is very disconcerting to me, because now you will be under more stress to not make a mistake, and this increased scrutiny can make it even more difficult for you to remain focused on giving good care. My other concern is that you should not be doing direct triage, almost every ER I have been with requires at least 1-2 years experience before the responsilbilty of triage is placed on a nurse. Good Luck!

[TrudyRN]

Have you thought about exploring other areas of nursing? I say this because it sounds like your learning style may not be compatible with the EC. You may need something slower paced so you can take it all in. You can not say that someone has chest pain that is not of a cardiac nature. The Docs diagnose. It is your job to A. Send cardiac enzymes B. MONA C. Stat EKG and D. Start an IV. You must always have access... what if he were to code and you have no access? You are fumbling around trying to start an IV and because you have no access ACLS is being stunted. It is sloppy nursing, and thats not an excuse. You can't have a sloppy day in nursing, especially when you work in EC or ICU where it is life or death for your patients.

There just simply isn't time for sloppy. I don't want to discourage you, but there is a niche in nursing for everyone and for some it takes a little longer than others to find it. Good luck with everything, and who knows, maybe you will come out of your extra orientation with a renewed sense of resolve and thoroughness.

OP, I hope you don't take this post to heart. I hope you do not allow yourself to be discouraged from doing what you want, which is ER, just because you are still new and still weak, coupled with an impatient boss, an incomplete orientation, and a lazy doc who thinks you should be able to read his mind. The suggestion to find a slower-paced area is moot - there are no slower-paced areas. Not these days. As for your learning style, diagnose it and try to get it utilized there in the ER.

When I was a brand new grad, I went to the OR, where I did not fit in, personality-wise, with the evil witches who ran the place. Crabby, impatient, cruel, smile in your face while stabbing you in the back people. Then a doc told the boss I wasn't ready to solo yet so they gave me a week more of orientation. Apparently, I guess I didn't meet their standards then either, (although they seemed to think I was adequate to be forced to work overtime whenever they needed somebody for that) as they then put me in Cysto, which is more like a doc's office than it is like the rest of the OR. I transfered out, which I'm sure is what they wanted. Funny though - I became a stellar OR nurse at another hopsital a couple of years later. My success was due to a different hospital culture and maybe my being a little older and having a little experience helped, too. But I did fine, became a supervisor, wish I'd never left.

Yeah, it's good to own up to your mistakes but I see fault with the doctor for giving an incomplete order, fault with your boss for not giving you the extra time you knew you needed and which you requested to orient, fault with the doctor giving a verbal order instead of writing it, fault with whoever did not tell you that every single CP gets an IV, EKG, etc., if that is indeed the case where you work.

As for determining the cause of CP, maybe nurses shouldn't do that but we all know that nurses have to form an impression/diagnose quite frequently. We have to know as much Medicine as the docs, just as a person has to know as much about the car as the car guy, as an example.

Follow your heart. Stay, leave, whatever on YOUR terms. I hope your time with the veteran nurse proves to be just what you need to get you fully up and running. BTW, things will come up from time to time that will not have been covered, no matter how long an O you get.

Take notes, review them, quiz yourself.

[TrudyRN]

There should be a protocol for chest pain, which includes IV to KVO until diagnostics are done.

The doc should specify route of ANY med. (toradol for chest pain??)hmmm....

You cannot assume that the symptoms are not cardiac in nature. We do not diagnose.

I think they just want you to be more careful with patient assessment and I think it is a very good idea to extend your orientation with a seasoned nurse who reviews your care.

Don't take this personally. They are protecting you, themselves and the patient.

If we don't diagnose, why should she assume it IS cardiac? That also would be diagnosing. :uhoh21: