Verbal er orders...help me understand this

[tiltgirl]

I work in california, have worked in the same facility for 3 years, have never been written up for a med error or been disciplined for my work ethic in the er. I received a phone call today from my manger stating that the verbal order from the pa for 1 mg of dilaudid was not signed by the pa and that the pa stated that the verbal order was never given to me and the pa filed a formal complaint against me stating that i was acting as a md and was called to have a formal hearing with my union rep about my job. I not only got the verbal order from the pa but also confirmed with the md....who i am hoping recalls and will sign the order off........the comment made to me was that the pt already received 8 of morphine.....which did not relieve the pt's pain.......and s/p xrays was vocal and crying s/p a motorcycle accident with a r/o fx to the left ankle. Pt had a hematoma from the ankle to the shin and a previous ankle fx. It was approx. 45 mins to an hour.....before the dose of dilaudid. It is standard practice in the er that we take verbal orders.....as we have 1 or 2 md's on and maybe a pa......at any given time and on nights we have one md only. I would never act out of malice or give a pt any medication if i did not think i had an order. My job is on the line here.....i need thoughts and prayers please......

[Rodoon, BSN, MSN, RN]

Another option I didn't see mentioned, is to ask a colleague to be given the verbal order after you. If another nurse is standing by, what could it hurt? Your best protection isn't a union rep. It's a witness. The other colleague doesn't need to hear a report from you, they should ask the person's name and then for them to repeat the order. The second person watches you write out the order and initials after your name. This avoids mistakes. It's proactive and professional. That way it would be harder to pretend a unit nurse is making up orders. Nurses need to get together to stop this type of problem.

The other solution is a special phone where calls are recorded and used only for verbal orders. Frankly, I prefer this solution.

[mudd68]

Agree with alot of the suggestions here. I have another idea! No more verbal orders, or let's record them somehow, lol! (I know not practical so don't slam me). But really, if the doctor can only give a verbal he can just give the med his or herself and document! Please let us know what happens. Good luck.

[Esme12, ASN, BSN, RN]

Many departments,unbeknownst to them, actually have a no verbal order policy except for emergencies.......even though no one follows it.

EVERYONE PLEASE, PLEASE....check you policies. Even the most trusted provider will safe their own behind when the chips fall......after being a nurse in this environment for 34 years, believe what I say.

[sserrn, BSN]

Mudd, it is not impractical at all. I work in 3 ERs, and we're not allowed to take verbal orders in any of them except in emergent situations. And even then, nurses don't write the orders...the doctors just write the order after we give it.

[Patti_RN]

Esme makes a good point about knowing policy before being thrust into a situation where actions may be contrary to policy.

But, employers sometimes claim the opposite...and employees have actually been reprimanded and terminated for what is known as 'belligerent compliance to company policy'. Yes, hard to believe, but true. It happens when a company perceives that an employee uses policy to refuse to do their job efficiently. (This is mostly associated with 'Bad Attitude Syndrome' so be careful! and in those cases it can be a legitimate issue.)

When a doc or PA gives you a verbal order, you have (basically) two choices: comply with the order (then risk having the PA or doc later claim they didn't give you that verbal), or you can refuse to do it because, "Hospital policy 4.3.1 states..." (Then the PA or doc goes crying to your supervisor that you refused)... Either way, you risk disciplinary action.

[jenfromjersey]

I had a similar situation occur with a doc. It was a Percocet order. He told me to give 2 tabs and then when I gave it and asked him to put the order in so I could document I gave it, he said he only wanted one tab not 2. When I said that he clearly told me 2 tabs not 1, he argued with me that he would never give me that order for the particular patient in question due to their age/diagnosis. I am not crazy, not frazzled easily and know what I clearly heard. I took it up with my manager at that very moment and I guess since the patient was still in the ER being monitored and there was no adverse outcome documented, it was handled within our department wihtout incident. However, from that point on (which was several years ago) I NEVER, EVER take a verbal order from him for anything, not even Tylenol. When he barks out an order, I respond "When I see the order in the computer, I'll give it". I am not talking about code situations. I am talking about a pain med, fluids, etc.

I had a doctor ask me once, while in the room with the patient, if I was giving the Ativan he ordered. He never ordered Ativan. I told him, in front of the patient, if you order Ativan, I gladly give it. I don't know why some doctors try to make it look like the nurse's fault that medications aren't given in a timely manner. He probably promised the med to the patient, never ordered it and then tried to make it look like it was the nurse who was the one holding out.

I have to say that I have a terrific working relationship with the large majority of docs in my ED. I do still take verbal orders from them and never have issues. However, there are 2 or 3 that I will NEVER take a verbal order from and will only medicate patients or perform tasks such as blood draws or IV starts once the orders are visible in the computer. It's about trust and once that trust is broken, you need to procees with caution when dealing with them in the future.

I am interested to know how this turns out.

[lirpaloof77]

Our ER also has a no verbal order policy except for emergencies. With that being said, it happens ALL THE TIME as the MD's don't feel like taking the time to put the order in the computer. We have found a way around this. Whenever I need a verbal for something like pain meds etc. I write it out and then have the MD sign my order. It goes from a verbal order to a written order in 2 seconds flat. Much much better way of doing things. If they don't put the order in the computer within a reasonable amt of time, I just scan the written order to the pharmacy and they input it :)

Good luck to you. That PA sucks and he/she sure is lucky that they don't work with me :)

[ecerrn]

I agree with those who state no verbal orders unless you're in a code..then there's usually more than one person there....even if they want it NOW, I have written it in the Dr chart as a v/o, as documentation as well as a favor to the doc, now that its all on the computor they gotta write it. If they don't you need to continue to document the outcome of previous meds given. For that bad a fx you better give me adequate narcotics or that doc will be speaking to my attorney. Narcotics wear off rather quickly and 10 mg of morphine won't last forever...who knows about previous fx and possible tolerances which also need addressed. They are also not toxic, so as long as they aren't allrgic, and you should ask again before you give it...sorry this happened, I hope your employers back you up and use this as a learning experience. Never trust anyone with your pt and meds, document, document, document. Lesson learned. Most pas have to ask Dr permission to give narcotics, sometimes I go with them to hear it from the horses mouth...personally, I'd much rather work with arnp.

[DC Collins, ASN]

I will gladly give meds, even narcotics, on a verbal order, *if*:

1) I have a great, trusting working relationship with the provider, and,

2) timing is very important (doc is doing a procedure or something emergent and the pt is in severe pain)

In less urgent cases where the doc is busy, maybe on the phone or something, I will save the doc time and write the order myself (as VORB), pull up the meds, then have the doc sign just before I give the meds.

DC :-)

[Esme12, ASN, BSN, RN]

I have seen very great nurses with excellent trusted relationships with the MD's/providers be thrown under the bus. My suggestion as always is KNOW your policy and make the MD's follow it as well.....Sadly, it will come back and bite you someday.